Diabetes and Cardiovascular Disease Provider Reference Guide (Prg)

Home , Diabetes medication, Random glucose test

Diabetes and Cardiovascular Disease Provider Reference Guide (prg)

Diabetes Quality Improvement Project

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider referen2ndce guide ed .,. July 2011 2011 i Disclaimer & Terms of Use

The Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2011 (2nd ed.) is intended for physicians and health care professionals to utilize as a decision-making aid in the diagnosis, management and education of patients with type 2 diabetes.

While the PRG describes recommended courses of intervention, it is not intended as a substitute for the advice of a physician or other knowledgeable health care professionals. We encourage all healthcare professionals to use their best clinical judgment as the recommendations may not be appropriate in all encounters. Any application of these recommendations should be made in consideration of the needs, conditions and circumstances of each individual patient.

The PRG represents best clinical practices at the time of publication, with the recognition that guidelines and practice standards may change as more knowledge is gained.

Unless otherwise stated, all material in the PRG may be reproduced with credit to the “CMA Foundation, Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2011 (2nd ed.).”

Diabetes Quality Improvement Project 3835 N Freeway Blvd Ste 100 Sacramento, CA 95658 Phone: (916) 779-6643 Fax: (916) 779-6658

www.thecmafoundation.org/projects/aped

3835 N. Freeway Blvd., Ste. 100 Sacramento, CA 95834 Despite our collective best efforts, the prevalence of diabetes continues to grow

Tel: 916.779.6620 across the United States. According to latest estimates from the Centers for Disease Fax: 916.779.6658 Control and Prevention (CDC), diabetes now affects 26 million people in the 1 www.thecmafoundation.org United States. This means that over eight percent (8.3%) of Americans have

diabetes. BOARD OF DIRECTORS

Dexter Louie, MD Chair Over the past few years, there has been an increasing effort to educate healthcare Associate Medical Director Chinese Community Health Plan providers about the need to address the cardiovascular risks and complications

David Holley, MD associated with diabetes. In fact, in April 2011, the American Association of Vice Chair Clinical Endocrinologists (AACE) issued clinical guidelines that call for Chairman NORCAL Mutual Insurance Company comprehensive management of the patient with diabetes to include consideration of 2 Francis J. Crosson, MD cardiovascular risk in addition to glycemic control. Secretary-Treasurer Senior Fellow The Kaiser Permanente Institute for This Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2011 Health Policy nd (2 ed.) was developed with the goal of bringing to healthcare providers in a variety Raquel D. Arias, MD Associate Dean, Educational Affairs, of practice settings current clinical guidelines, best practices and patient self Special Projects Associate Professor, Obstetrics and management resources, all in one easy-to-use guide. Coordinated by the California Gynecology Medical Association (CMA) Foundation, 29 physicians and other healthcare

Paul B. Carroll professionals contributed to the update of the PRG content. What has come of their Principal Devil’s Advocate Group efforts is a key resource that is evidence-based and contains the most effective ways

Dustin Corcoran to prevent, assess and manage diabetes and its cardiovascular complications. Chief Executive Officer California Medical Association New for 2011: Lisa Folberg Vice President • Identification and management of prediabetes Medical and Regulatory Policy California Medical Association • An updated “Management” chapter that integrates blood glucose, hypertension

Dev GnanaDev, MD, MBA, FACS and hyperlipidemia management all in one chapter (reflecting a more Immediate Past President comprehensive management of diabetes) California Medical Association

James G. Hinsdale, MD • Adult outpatient insulin guidelines for type 2 diabetes, including a decision President-Elect matrix, from the Diabetes Coalition of California California Medical Association • Physical activity guidelines for type 2 diabetes Carol A. Lee, Esq. President and CEO • Tips to improve medication adherence CMA Foundation • Updated pharmacotherapy grids to treat and manage diabetes, hypertension Anmol S. Mahal, MD Medical Director and dyslipidemia Free Medical Clinic at • A Diabetes Care Guidelines & Flow Sheet that allows you to easily identify all India Community Center with the American Association of Physicians of recommended care for your patient compared to target goals – all on a single Indian Origin page J. Mario Molina, MD Chairman and CEO • Updated ICD-9-CM codes Molina Healthcare, Inc.

Diana E. Ramos, MD, MPH Please join the efforts of the CMA Foundation as we work in collaboration with Medical Director Reproductive Health Programs physicians, healthcare providers, health plans and other stakeholders to advance the Los Angeles County Public Health Department practice of diabetes care and promote better patient self management and adherence.

Austin A. Robinson You can find a web-based version of the PRG and additional practice and patient Medical Student resources by going to the CMA Foundation’s Diabetes Quality Improvement David Geffen School of Medicine at University of California Los Angeles Project’s website at www.thecmafoundation.org/projects/aped. For more

Michael Steenburgh information about the CMA Foundation, please visit us at Executive Director San Joaquin Medical Society www.thecmafoundation.org

Scott Syphax President and CEO Sincerely, Nehemiah Corporation of America

Robert E. Wailes, MD Medical Director Pacific Pain Medicine Consultants Dexter Louie, MD Chair, CMA Foundation Board of Directors

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 iii CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table of Contents

Preface - About the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG) • Acknowledgements...... x • Making and Using the PRG...... xi • Diabetes and Cardiovascular Disease Overview...... xii 1 Prevention and Delay of Type 2 Diabetes • Prediabetes...... 4 • Obesity...... 5 • Metabolic Syndrome...... 8

2 Screening and Diagnosis of Type 2 Diabetes, Hypertension and Dyslipidemia • Signs and Symptoms of Type 2 Diabetes...... 10 • Assessing Adult Risk for Diabetes and Cardiovascular Disease...... 10 -Contributing Risk Factors...... 10 -American Diabetes Association (ADA) Risk Test...... 11 -Framingham Risk Score...... 11 -Cardiovascular Disease Evaluation Considerations...... 12 • Screening and Diagnostic Testing...... 13 • Type 2 Diabetes Screening and Diagnostic Criteria...... 14 -Screening in Asymptomatic Adults...... 14 -Hypertension Screening and Diagnosis Criteria...... 15 -Dyslipidemia Screening and Diagnosis Criteria...... 17

3 Comprehensive Management of Type 2 Diabetes • Diabetes Care Guidelines/Flowsheet...... 20 • Achieving Glycemic Control...... 22 -A1c Recommendations...... 22 -Blood Glucose Level Goals...... 23 -Monitoring Blood Glucose Levels...... 23 -Proper Disposal of Syringes and Needles...... 25 -Patient Logs and Worksheets...... 26 -Pharmacotherapy...... 26 -Insulin Guidelines...... 30 -Hypoglycemia...... 36 • Clinical Management of Hypertension...... 36 -Target Blood Pressures and Self Measurement...... 36 -Hypertension Treatment Algorithm, Initial Drug Choices...... 37 -Pharmacotherapy for Hypertension...... 38 -JNC 7...... 43 • Clinical Management ofDyslipidemia...... 45 -Targeting Adult Cholesterol Levels...... 45 -Pharmacotherapy for Dyslipidemia...... 47 -ATP III At-A-Glance...... 50

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 v • Lifestyle Interventions and Modifications...... 56 -Recommended Lifestyle Modifications...... 56 -Weight Loss/Maintenance...... 57 -Medical Nutrition Therapy (MNT)...... 57 -General Nutritional Recommendations For Diabetes...... 58 -Nutritional Recommendations for Weight Loss In Diabetes...... 58 -Physical Activity and Exercise In Diabetes...... 58

4 Preventing and Managing Complications of Type 2 Diabetes • Acute complications...... 60 -Hypoglycemia ...... 60 -Diabetic Ketoacidosis (DKA)...... 61 • Long Term Complications...... 61 -Foot Care...... 62 -Depression and Mental Health...... 66 -Dental and Oral Care...... 69 -Eye Health...... 70 -Renal Health...... 71 -Nervous System...... 72 -Tobacco and Smoking...... 73

5 Improving Type 2 Diabetes Care and Self Management • Patients as Decision-Makers...... 76 • Supporting Lifestyle Change...... 76 -Patient and Provider Communication...... 77 -Readiness for Change...... 78 -Tips for Supporting Patient Lifestyle Modifications...... 79 • Brief Negotiations - Assessing Readiness to Change...... 80 -Diabetes - General...... 81 -Weight - General...... 84 -Sample Dialogues Using Brief Negotiations...... 86 • Insulin Introduction Sample Dialogue...... 86 • Hypertension Self-Management Sample Dialogue...... 88 -Brief Negotiations Reference Card...... 89 • Improving Medication Adherence ...... 90 -Factors that Influence Adherence...... 90 -Tips to Improve Adherence...... 91 • Systems and Process Improvement...... 92 -Office Systems...... 92 -Chart Prompts...... 92 -Exam Rooms/Waiting Area...... 92 -Building the Diabetes Team...... 93 -Patient Activation/Support...... 93

vi CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 6 Patient Resources • General Care and Management of Diabetes...... 97 • Assessing Risk and Prevention for Diabetes...... 107 • Glycemic Control...... 111 • Insulin Management...... 116 • Diabetes and Cardiovascular Disease...... 119 • Neuropathy...... 123 • Nutrition...... 125 • Exercise...... 131 • Medication Adherence...... 134

7 Practice/Clinic Resources • CMAF DQIP Project Flyer...... 139 • California Diabetes Program...... 140 • Multicultural Patient Education Materials Database...... 142 • Reducing Cardiometabolic Risk...... 143 • Community Resource Directory...... 145 • Language Access Database...... 146 • Link to Informational Websites...... 147 • Billing and Coding Quick Reference Guide...... 148 -ICD-9-CM Coding for Type 2 Diabetes Mellitus...... 148 -ICD 9-CM Coding for Diabetes Risk Factors and Cardiovascular Comorbid Diagnoses...... 148 -ICD 9-CM Coding for Type II Diabetes Mellitus Diagnoses...... 152 -ICD 9-CM Coding for Diabetes Related Complications and/or Comorbidities...... 156 -HCPCS Level II Codes for Self Monitoring Blood Glucose Products...... 157 -HCPCS Codes Medicare Preventive and Screening Services...... 158 -HCPCS Codes Self Management Training Services...... 162 -CPT Codes Medical Nutrition Therapy (MNT)...... 163 -ICD-9-CM Codes Supporting (MNT)...... 164 -Billing and Coding Internet Resources...... 167

References ...... 168 Tables and Figures...... 171 Evaluation...... 174

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 vii viii CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Preface About the Diabetes and Cardiovascular Disease Provider Reference Guide (prg)

• Acknowledgements • Making and Using the PRG • Diabetes and Cardiovascular Disease Overview

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 ix Acknowledgements

The California Medical Association Foundation would like to thank the following individuals for their dedication to the Diabetes Quality Improvement Project. Their support, time, and expertise were critical to the development of this resource.

Community Practice Resident Solutions CVS Caremark McKesson Patient Relationship Medical Director Solutions East Main Clinic and Stockton Diabetes Intervention Center Case Manager / Quality Chairman, Scientific and Technical Health Plan of San Joaquin Senior Quality Improvement Committee Specialist South Stockton Diabetes Society Health Net Diabetes Care Coordination Project Manager Lead Assistant Clinical Professor Scripps Whittier Diabetes Institute Diabetes Nurse Specialist/ Director of IPPE Programs Consultant Department of Pharmacy Practice University of the Pacific General Practice Thomas J Long School of Patient Safety and Risk Management Pharmacy and Health Sciences Account Executive Clinical Program Manager The Doctors Company MedImpact Senior Project Manger The Permanente Medical Group, Director, Clinical Programs Inc. Chief Executive Officer WellPoint State Sponsored Business American College of Cardiology

Medical Director of Diabetes Manager Strategic Product Education Senior Area Health Promotion Development Sutter Medical Foundation Specialist CVS Caremark California Diabetes Program

Family Care Specialists Medical Vice President Analytics and Group Associate Director Outcomes Center for Economic Services CVS Caremark California Medical Association Senior Health Promotion Specialist Medical Consultant California Diabetes Program Professor & Associate Dean of CalPERS Graduate Medical Education and Student Affairs Director of Strategic Development UC Davis Health System Case Manager CVS Caremark Health Plan of San Joaquin

Board of Trustees Director of UCSF Asian Heart and California Medical Association Chronic Disease Program Director Vascular Center Alameda County, Public Health Immediate Past President Department California Chapter, American Research Associate College of Cardiology California Medical Association Former Governor Northern California, American College of Cardiology Director, Client Strategy and

x CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Making and Using the PRG The Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2011 (2nd ed.) was first published in 2010 by the California Medical Association (CMA) Foundation. The impetus for its creation was to provide healthcare providers with an easy-to-use tool that would help reduce the risk of comorbidities that often affect patients with diabetes, such as heart attack, congestive heart failure and chronic kidney disease. By describing the comprehensive management of diabetes to include hypertension and lipid management, the PRG presents the opportunity to improve diabetes-related clinical processes and patient outcomes that lead to healthier individuals and communities.

This second edition of the PRG is the product of countless hours of review of current clinical guidelines, medical literature and patient education materials by a dedicated team of physicians and other healthcare professionals with an expertise in diabetes care and cardiovascular risk management. Each of the chapters contains sections that provide information on key aspects of diabetes care. Throughout, you will find practical tips and tools to easily facilitate the integration of the recommendations into clinical practice.

The PRG can be viewed and downloaded via the web by going to: www.thecmafoundation.org > Publications

Audience The intended audience for the PRG are physicians and other healthcare providers who care for patients with type 2 diabetes, or who are part of the patient’s diabetes care team including pharmacists, nutritionists, certified diabetes educators and others. The PRG can also be used by health plans and other health systems that support healthcare providers in their quest to provide the highest quality, patient- centered care possible.

Corporate Sponsors The second edition of the PRG is supported with funding from the following corporate sponsors: • AstraZeneca • Daiichi Sankyo, Inc. • Sanofi-aventis U.S. • Takeda Pharmaceuticals The PRG was developed independently and without control or influence of the above corporate

sponsors. The CMA Foundation retains full control of the PRG’s planning, content and execution.

About the Diabetes Quality Improvement Project

The PRG is a product of the CMA Foundation’s Diabetes Quality Improvement Project (DQIP). The goals of the project are to:

1. Improve the quality of care provided to diverse patients with type 2 diabetes 2. Effectively prevent and manage the cardiovascular risks and complications associated with diabetes 3. Support physician office capacity to improve, track and monitor diabetes care 4. Share best practices associated with providing quality diabetes care 5. Provide multicultural community and patient education materials through online resources

Comments on the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG), 2009-2010 (1st ed.)

“The PRG is easy to comprehend and practical, with an informative global clinical approach ideal in a family practice setting, that has an ultimate goal of preventing cardiovascular events.” “If someone is going down the wrong road, he doesn’t need motivation to speed him up. What he needs is education to turn him around.” “Ever wondered if there was an authoritative source of diabetes management that is up to date and practical, The PRG is the place.”

Diabetes Prevalence In California, 13.5% of the population, or 1 in every 7 adults, has diabetes.3 New cases of diabetes increased 36% over the last decade, ranking California first among all states in terms of the greatest number of annual new cases.

Nationally, according to a 2011 report issued by the Centers for Disease Control and Prevention (CDC), there are nearly 26 million people, with diabetes.1 Of this figure, 7 million people are undiagnosed. This represents an increase of more than 8% from the previous CDC estimate in 2007. The costs, both indirect and direct, of diabetes is estimated at $174 billion.1

The CDC projects the prevalence of diabetes to rise sharply over the next 40 years due to factors such as an aging population and an increasing number of Americans whose ethnic background places them at greater risk of developing type 2 diabetes.4 The CDC’s estimate is that as many as 1 in 3 Americans will have diabetes by 2050. This does not include the number of adults with prediabetes, which is estimated to be one-third of the entire US adult population.

Considering the current and future projections of diabetes prevalence, it is no wonder that healthcare providers and health systems are struggling to keep pace with providing high quality, patient-centered and cost effective care and management to this growing population.

Disparities in Diabetes1 Data show that race and ethnicity correlate with persistent disparities in health. Rates of type 2 diabetes are significantly higher among certain ethnic groups. For example, African Americans and Hispanic adults are twice as likely to be diagnosed with diabetes than non-Hispanic Whites. Native American adolescents 19 years of age and younger are more likely than any other group to be diagnosed with type 2 diabetes. In California, Latinos (24%), American Indian/Alaskan Natives (24%) and African Americans (20%) between the ages of 50-64 have higher rates of diagnosed diabetes than Whites (7%).

Because ethnic groups will continue to comprise a growing proportion of the population, the health of the U.S. population is dependent on how well we can make improvements in the health and well being of these groups. Disparities in healthcare often result from socioeconomic factors, the environment, a lack of health resources and inadequate care and management to prevent disease. Interventions that are culturally and linguistically appropriate, based on recommended clinical guidelines, grounded in the community and comprised of multidisciplinary groups and individuals and organizations will help support improvements in these populations.

Diabetes Complications Without effective and early intervention, patients with diabetes are at risk for major complications such as blindness, end-stage renal disease, amputations, heart disease and stroke. In fact, heart disease and stroke are the number one cause of death and disability among people with type 2

xii CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 diabetes.5 Members of ethnic groups are disproportionately affected by higher rates of death and disability due to diabetes, which may be attributed to disparities in access to care and routine preventive care and treatment.6 For example, heart failure is striking African Americans in their thirties and forties at the same rate as non-Hispanic Whites in their fifties and sixties.7

Fortunately, lifestyle modifications such as better nutrition, improved fitness and weight loss can prevent or delay diabetes. For patients who are already diagnosed, lifestyle change coupled with medication management can significantly delay, prevent and/or manage the variety of diabetes- related complications. Both healthy lifestyle and medication management are key components of clinical treatment guidelines for patients with diabetes.8,9

Diabetes and Cardiovascular Disease Link Cardiovascular disease is defined as a class of diseases that include coronary artery disease (CAD), cerebrovascular disease, and peripheral arterial disease. Cardiovascular disease (CVD) is the primary cause of death for most people with diabetes.5 Hyperlipidemia, dyslipidemia, and hypertension are strong risk factors for cardiovascular disease.

Hypertension affects an estimated 50 million individuals in the United States, posing a major public health challenge. CDC estimates that 1 out of 3 American adults have high blood pressure. By ethnicity, it affects 2 in 5 African Americans, 1 in 6 Asians and 1 in 5 Hispanics and Native Americans. It is known as the “silent killer” as many people are asymptomatic.10

The American Heart Association estimates 98.8 million Americans over the age of 20 have total blood cholesterol levels that are higher than the recommended 200 mg/dL.11 While most individuals with high cholesterol levels have no visible symptoms, over time elevated cholesterol levels result in narrowing and hardening of the arteries (arteriosclerosis or atherosclerosis) reducing the overall blood flow to the heart. The reduced blood flow increases the risk of myocardial infarction, stroke, kidney disease and eye damage.

A comprehensive treatment plan for patients with diabetes includes modification of these cardiovascular risk factors through lifestyle modification and medication management. It also includes the use of a multidisciplinary team to connect the patient with needed services and support long term self-management goals.8

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 1 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Prevention and Delay 1 of Type 2 Diabetes

Prediabetes • Preventing Diabetes • Communicating with Patients about Prediabetes

Obesity • Health Consequences of Obesity • The Body Mass Index • Classification of Overweight/Obesity and BMI • Measurement of Waist Circumference • Overweight and Obesity Resources

Metabolic Syndrome

Diabetes can be delayed or prevented by following a healthy lifestyle, including making improvements in diet and increasing physical activity.

Prediabetes Patients with prediabetes have blood glucose levels that are higher than normal but not high enough for a diagnosis of diabetes. Having prediabetes places patients at a significantly higher risk for developing diabetes.8,9

Table 1: Categories of Increased Risk for Diabetes (Prediabetes) T aBLe 1 Categories of Increased Risk for Diabetes (Prediabetes)

Test Result Diagnosis Fasting Plasma Glucose or 100-125 mg/dL Impaired Fasting Glucose 2-h plasma glucose (in the 75g OGTT) or 140-199 mg/dL Impaired Glucose Tolerance A1c 5.7% - 6.4% High risk/prediabetes; requires screening by glucose criteria

Preventing Diabetes8,9 The development of type 2 diabetes can be prevented or delayed through early intervention.

• Monitor patients to assess glycemic status at least annually • Monitor CVD risk factors such as elevated blood pressure and dyslipidemia at regular intervals • Discuss and help patients set lifestyle modification goals; refer to available support programs ° 5% - 10% loss of body weight if overweight or obese ° ≥150 minutes of moderate/vigorous exercise per week • Consider metformin for primary prevention in patients at highest risk for developing diabetes (e.g. progression of hyperglycemia, CVD risk factors)

Communicating with Patients about Prediabetes12 Patients with prediabetes need to understand the following:

• Diabetes is a lifelong chronic disease that can be prevented/delayed • Losing a modest amount of weight (5% - 10% if you are overweight/obese) can help prevent/delay type 2 diabetes • Preventing diabetes can help you lead a healthy life without serious complications from the disease such as heart disease, stroke, blindness, kidney failure and amputations

4 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 D d P r ia el even be a y of Ty t e ti s on p a e 2 n d Obesity13 Obesity significantly increases the risk of developing other health problems, and more than one third of U.S. adults—more than 72 million—people are obese. The obesity-related medical care costs in 2008 were estimated to be as high as $147 billion.

Health Consequences of Obesity Obesity has physical, psychological, and social consequences for adults and children. The health consequences of obesity are more severe among patients with diabetes.

The Health Consequences of Obesity

• Coronary heart disease • Type 2 diabetes • Cancers, such as endometrial, breast, and colon • High blood pressure (hypertension) • High total cholesterol or high levels of triglycerides (dyslipidemia) • Stroke • Liver and gallbladder disease • Sleep apnea and respiratory problems

• Degeneration of cartilage and underlying bone within a joint (Osteoarthritis) • Reproductive health complications

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 5 Body Mass Index The body mass index (BMI), also known as the Quetelet index, is used far more commonly than body fat percentage to identify obesity. BMI is closely correlated with the degree of body fat in most settings. BMI = (weight in lbs * 703) / height in inches2

The table below describes the classification of overweight and obesity.14 You will also find a BMI table.

Table 2: Classification of Overweight/Obesity and BMI Table Tlab e 2 Classification of Overweight/Obesity and BMI Table

Disease risk* (relative to normal

weight and waist circumference) Men 40 in (102 BMI (kg/m2) Obesity class >40 in (102 cm) cm)

Women 35 in (88 >35 in (88 cm) cm) Underweight <18.5

Normal† 18.5 to 24.9

Overweight 25.0 to 29.9 Increased High Obesity 30.0 to 34.9 I High Very high

35.0 to 39.9 II Very high Very high

Extreme 40 IIII Extremely high Extremely high obesity

* Disease risk for type 2 diabetes, hypertension, and coronary heart disease. † Increased weight circumference can also be a marker for increased risk even in persons of normal weight.

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Height Body Weight (pounds) (inches)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287

6 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 D d P r ia el even be a y of Ty t e ti s on p a e 2 n d Measurement of Waist Circumference Measurement of waist circumference is a second obesity assessment tool to determine an individual’s degree of excess abdominal fat. Abdominal fat poses a greater health risk than peripheral fat, and waist circumference may be more predictive of disease risk than BMI in normal or overweight patients.15 It is important to note that waist circumference is measured at the level of the iliac crest, not the umbilicus (“natural” waist). Healthcare providers should explain the importance of waist circumference measurements as part of the medical assessment. Figure 1: Measuring Waist Circumference

Figure 1: Measuring Waist Circumference

To measure patient waist circumference:

 Locate the upper hip bone and top of the iliac crest when patient is standing.  Place a measure tape in a horizontal plane at the level of the iliac crest around the abdomen ensuring the tape is snug and parallel with the floor.  The patient should be asked to breathe normally while the measurement is taken. The measurement should be read at the end of patient exhalation.

Overweight and Obesity Resources • American Heart Association: http://www.heart.org • Centers for Disease Control and Prevention: http://www.cdc.gov/obesity/ • National Heart, Lung, and Blood Institute – Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: http://www.nhlbi.nih.gov/guidelines/obesity/ ob_home.htm • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) – Weight Control Information Network (WIN): http://win.niddk.nih.gov/Publications/tools.htm

Metabolic syndrome (MetS) is defined by a combination of conditions that result from a higher risk for coronary artery disease. Conditions include type 2 diabetes, obesity, high blood pressure, and a poor lipid profile with elevated LDL (“bad”) cholesterol, low HDL (“good”) cholesterol, and elevated triglycerides due to the association with higher blood insulin levels. The fundamental metabolic syndrome defect is increased insulin resistance in both adipose tissue and muscle. A proinflammatory and prothrombic states are also common in persons with metabolic syndrome. While patients with excess body fat who are physically inactive are at greater risk for developing insulin resistance, some individuals have a genetic predisposition to developing the syndrome. Drugs used to decrease insulin resistance usually have the added benefits of lowering blood

pressure and improving the lipid profile.

Table 3: Criteria for Clinical Diagnosis of Metabolic Syndrome Tlab e 3 Criteria for Clinical Diagnosis of Metabolic Syndrome

Measure (any 3 of 5 constitute Categorical Cut points diagnosis of metabolic syndrome)

Elevated waist circumference* Population and Country Specific Definitions

Elevated triglycerides (drug treatment ≥150 mg/dL (1.7 mmol/L) for reduced HDL-C is an alternate

indicator†)

Reduced HDL-C (drug treatment for <40 mg/dL (1.0 mmol/L) in men reduced HDL-C is an alternate <50mg/dL (1.3 mmol/L) in women indicator†)

Elevated blood pressure Systolic ≥ 130 mm Hg and/or (antihypertensive drug treatment in a Diastolic ≥ 85 mm Hg patient with a history of hypertension is an alternate indicator)

Elevated fasting glucose‡ (drug treatment ≥100 mg/dL of elevated glucose is an alternate indicator)

HDL-C indicates high-density lipoprotein cholesterol. *It is recommended that the IDF cut points be used for non-Europeans and either the IDF or AHA/NHLBI cut points used for people of European origin until more data are available. †The most commonly used drugs for elevated triglycerides and reduced HDL-C are fibrates and nicotinic acid. A patient taking 1 of these drugs can be presumed to have high triglycerides and low HDL-C. High-dose ω-3 fatty acids presumes high triglycerides. ‡Most patients with type 2 diabetes mellitus will have the metabolic syndrome by the proposed criteria.

From Alberti et al, “Harmonizing the Metabolic Syndrome”, Circulation, 2009.18

8 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Screening and Diagnosis 2 of Type 2 Diabetes, Hypertension and Dyslipidemia

• Signs and Symptoms of Type 2 Diabetes

• Assessing Adults Risk for Diabetes and Cardiovascular Disease -Contributing Risk Factors -American Diabetes Association (ADA) Risk Test -Framingham Risk Score (FRS) -Cardiovascular Disease Evaluation Considerations

• Screening and Diagnostic Testing

• Type 2 Diabetes Screening & Diagnosis Criteria -Screening in Asymptomatic Adults

• Hypertension Screening and Diagnosis Criteria -Diagnosing Hypertension -Ambulatory Blood Pressure Monitoring (ABPM) -Classification of Blood Pressure

• Dyslipidemia Screening and Diagnosis Criteria -Screening for Dyslipidemia -Classification of Lipid Profile

Early detection and intervention of individuals with diabetes is key to preventing and/or managing the long-term complications of the disease. The initial patient assessment should include vital signs, consideration of medical and family history, cardiovascular risk, physical examination, and laboratory testing to confirm a diagnosis and support the evaluation of contributing risk factors.

Signs and Symptoms of Type 2 Diabetes19

Type 2 Diabetes

The following are common signs or symptoms that may indicate diabetes. However, many people with type 2 diabetes are asymptomatic.

Table 4: Common Signs and Symptoms of Diabetes

• Delayed wound healing • Polyuria • Fatigue and irritability • Polyphagia • Frequent infections • Numbness or tingling in the hands or feet • Recurring skin, gum or bladder • Sudden unexplained weight loss or weight gain infections • Unusual thirst / dehydration • Blurred vision

*The American Diabetes Association identifies the above symptoms of diabetes

Assessing Adult Risk for Diabetes and Cardiovascular Disease8,9,20

Contributing Risk Factors

Risk factors for developing type 2 diabetes and cardiovascular disease (CVD) often cluster to include obesity, insulin resistance, hyperglycemia, dyslipidemia, and hypertension (see Figure 2).

These diseases can occur in isolation and are further exacerbated by poor lifestyle behaviors that include physical inactivity and smoking.

10 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Figure 2: Factors Contributing to Cardiometabolic Risk

d h Ty D S cr y y iag p s p e 2 l e een no ipid rt dia sis en i n e g si mia be of

a on t n e d s a , n d

Am Coll Cardiol 2008; 51: 1512-1524 Source: Brunzell, J. D. et al. J

American Diabetes Association (ADA) Risk Test The ADA Risk Test is a simple tool that can be used to help determine a patient’s risk for prediabetes and diabetes. The test is available in English http://www.diabetes.org/diabetes-basics/ prevention/diabetes-risk-test/ and Spanish http://www.diabetes.org/espanol/todo-sobre-la-diabetes/sintomas- de-la-diabetes/examen-de-riesgo.html and can be accessed from the American Diabetes Association’s website at www.diabetes.org.

Framingham Risk Score (FRS)19,30 The Framingham Risk Score (FRS) estimates 10-year risk of developing “hard” coronary heart disease events (myocardial infarction and coronary death) for adults aged 20-79 who do not have heart disease or diabetes. The risk factors used in the calculation are age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, and cigarette smoking.

FRS calculation tools are available in a variety of formats that include risk charts, tools for use on smart phones, Personal Digital Assistants (PDAs), spreadsheet calculators for personal computers, and web-based calculators.

Go to the National Cholesterol Education Program (NCEP) website at www.nhlbi.nih.gov to access a web-based Framingham calculation tool http://hp2010.nhlbihin.net/atpiii/calculator.asp and/or risk estimate tables http://www.nhlbi.nih.gov/guidelines/cholesterol/risk_tbl.htm.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 11 Cardiovascular Disease Evaluation Considerations Healthcare providers should consider the following factors when evaluating and/or conducting a diagnostic workup for cardiovascular disease, including:23

Table 5: CardiovascularTlab e 5 Cardiovascular Disease Evaluation Disease Considerations Evaluation Considerations

 Individual patient risk factors and co-morbidities Age, >55 for men, >65 for Hypertension women Cigarette smoking Microalbuminuria, estimated Dyslipidemia glomerular filtration rate <60mL/min Diabetes mellitus Obesity, BMI ≥30 kg/m² Family history of premature Physical Inactivity CVD, men age <55, women age <65  Identifiable causes of hypertension including: Chronic kidney disease Pheochromocytoma (adrenal gland Coarctation of aorta tumors) Cushing syndrome with/without Renovascular disease steroid therapy Drug induced/related Sleep apnea Primary aldosteronism Thyroid disease

 Conducting a comprehensive history and physical examination

 Assessing for the presence of target organ damage including: Heart Left ventricular hypertrophy Angina or prior myocardial infarction (MI) Heart failure Prior coronary revascularization Brain Stroke Transient ischemic attack (TIA) Dementia Chronic kidney disease Peripheral artery disease Retinopathy

 Obtaining laboratory tests which may include: Blood glucose Lipid profile panel (after a 9-12 hour fast) Calcium Serum potassium Electrocardiogram Urinalysis Creatine (or the eGFR) Urinary albumin or Hematocrit albumin/creatinine ratio

12 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Screening and Diagnostic Testing d h Ty D S cr y y iag p Commonly used screening tests to support the diagnosis of diabetes, dyslipidemia and s p e 2 l e een no hypertension and diabetes include: ipid rt dia sis en i n e g si mia be of Table 5

Cardiovascular Disease Evaluation Considerations a

13 on t • Blood pressure (by auscultation)– (without proteinuria) <130/80 mm Hg; (with proteinuria n e d s a ,

<120/75 mm Hg; Pregnancy 110-129 mm Hg/65-70 mm Hg. n d

• Blood lipid (cholesterol) panel – Lipid testing measures the amount of total cholesterol, (LDL “bad” cholesterol and HDL “good” cholesterol) and triglycerides in the blood.

• A1c test – Also known as Hemoglobin A1c (HbA1c). A1c is a widely accepted measure used to screen for and monitor patients with diabetes. The test reports an average blood sugar level over a period of 3 months. A1c can be affected by conditions that affect red blood cell turnover (such as anemia and hemoglobinopathies like sickle cell disease), which needs to taken into consideration especially when the A1c result does not correlate with the patient’s clinical situation or home monitored glucose levels. o An A1c level of 5.7% to 6.4% is considered at risk for developing diabetes, i.e. prediabetes.24 o An A1c level of 6.5% or higher is considered consistent with a diagnosis of diabetes

• Fasting blood glucose test (FPG) – Fasting plasma glucose test (FPG) – This test is commonly used to diagnose diabetes. People without diabetes have fasting glucose levels <100 mg/dL. A value between 100-125 mg/dL is consistent with a diagnosis of pre-diabetes. A fasting plasma glucose value ≥ 126 mg/dL is consistent with a diagnosis of diabetes.

• Oral glucose tolerance test (OGTT) – The 75 gram 2 hour OGTT testing involves the oral administration of 75 grams of glucose (glucola) to determine how quickly it can be removed from the blood. The glucose level is checked after 2 hours. People without diabetes have levels <140 mg/dL. Impaired Glucose Tolerance (IGT) is diagnosed with values between 140-199 mg/dL. A 2 hour test OGTT ≥ 200 mg/dL is consistent with a diagnosis of diabetes.

• Random blood glucose test- A random glucose test is a plasma glucose which is obtained from someone regardless of when the patient last ate. A random plasma glucose of 200 mg/dL or greater in association with symptoms of diabetes is consistent with a diagnosis of diabetes.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 13 Type 2 Diabetes Screening & Diagnosis Criteria Diabetes is diagnosed based on presenting symptoms in combination with fasting or random plasma glucose test, an oral glucose tolerance test (OGTT), or an A1c. In addition to the patient’s physical exam results and medical history, genetic/chronic disease risk factors should be considered. To ensure that test results are accurate, patients being screened for diabetes should not be acutely ill. Patients may be allowed to drink coffee or tea without cream or sugar additive on the morning of the test. Regardless of the diagnostic method used in the diagnosis, testing should be repeated to confirm the initial results.

Screening for Diabetes in Asymptomatic Adults According to the ADA, adults < 45 years old should be screened for diabetes if they are overweight and obese and have one of the following risk factors. All adults should be screened once they are 45 years old regardless of risk factors. Screening should be repeated every 3 years.

Table Tl6ab: Criteriae 6 Criteria for for Testing Testing for for Diabetes in in Asymptomatic Asymptomatic Adults Adults

A1c ≥5.7%, Impaired Glucose Overweight 2 Tolerance, or Impaired Fasting o BMI ≥25 kg/m Glucose on previous testing Age Sedentary lifestyle o ≥45 years of age Dyslipidemia Women diagnosed with o HDL cholesterol level polycystic ovarian syndrome <35mg/dL (0.90 mmol/L) (PCOS) and/or o Triglycerides level >250mg/dL (2.82 mmol/L) First-degree relative with Women who delivered a baby diabetes weighing >9lbs or were diagnosed with gestational diabetes History of cardiovascular disease Other clinical conditions Hypertension associated with insulin resistance severe obesity o ≥140/90 mm Hg or on o therapy for hypertension o acanthosis nigricans waist more than 40 inches Members of a high-risk ethnic o population (e.g., African in men and more than 35 American, Latino, Native inches in women American, Asian American and Pacific Islander)

14 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 TableTlab 7: eDiagnosis 7 Diagnosis of Diabetes of Diabetes

d h Ty D S cr Test Notes Normal Pre-Diabetes Diabetes y y iag p s p e 2 l e een no

(increased risk for ipid rt dia sis en i

diabetes) n e g si mia be of

Fasting Fasting with no <100 100-125 mg/dL ≥126 mg/dL a on t n e Plasma caloric intake for mg/dL d s a , Glucose* at least 8 hours. n d Random Can be performed ≥200 mg/dL with Plasma regardless of symptoms Glucose timing of caloric intake. 75 gram Glucose load with <140 140-199 mg/dL ≥ 200 mg/dL Oral 75 grams mg/dL Glucose anhydrous Tolerance glucose in water. Test (OGTT)*

A1c %* < 5.7 % 5.7-6.4 % ≥ 6.5 % *Result should be confirmed by repeat testing in the absence of unequivocal hyperglycemia.

Hypertension Screening and Diagnosis Criteria Most people exhibit no signs or symptoms of hypertension. Untreated hypertension may lead to more severe symptoms associated with heart disease e.g. congestive heart failure and stroke. The following may indicate the presence of severe hypertension.

Table 8Tl:ab Signse 8 Signsand Symptoms and Symptoms of Severe of Severe Hypertension Hypertension

Blurred vision Palpitations Chest pain or pressure Papilledema Confusion Tachycardia Dizziness Leg edema Syncope Shortness of breath at rest Fatigue / decreased energy and/or during periods of Headache exercise

Diagnosing Hypertension23 Standardized blood pressure measurement technique, which includes using a sphygmomanometer (blood pressure cuff), should be used to confirm the initial diagnosis of hypertension. All elevated blood pressure readings should be confirmed during two subsequent follow-up visits as a basis for recommending treatment therapies and lifestyle modifications.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 15 Ambulatory Blood Pressure Monitoring (ABPM) Ambulatory blood pressure requires monitoring over a 24-hour period (every 15 minutes during the day and hourly at night). Clinical evidence is now available from longitudinal studies that affirm ABPM is a much stronger predictor of cardiovascular morbidity and mortality than conventional blood pressure monitoring. In 2002, the Centers for Medicare and Medicaid Services (CMS) approved ABPM for reimbursement. ABPM is diagnostic for patients with white coat hypertension and masked hypertension (reverse white coat hypertension). It is also helpful to assess patients with apparent drug resistance, hypotensive symptoms with antihypertensive medications, episodic hypertension, and autonomic dysfunction.

Uncomplicated hypertension without co-morbidities constitutes only 18% of the patients with hypertension. The vast majority of patients with hypertension have at least one additional risk factor. Hypertensive patients with diabetes, heart failure, high coronary risk, chronic kidney disease, and recurrent stroke comprise a special population of patients with compelling indications for which other drug classes should be considered as first line therapy (see table 9 below).

Classification of Blood Pressure (BP) The following classifications table outlined in JNC 7 does not support stratifying individuals by the presence or absence of risk factors or associated organ damages as a basis for differential treatment recommendations. The guidelines recommend that all individuals with stage 1 and 2 hypertension receive treatment.

TableTlab e9 :9 Classification Classification of Bloodof Blood Pressure Pressure

SBP DBP Lifestyle Initial Drug Therapy Classification (mm Hg) (mm Hg) Modification Encourage No antihypertensive Normal < 120 and <80 drug therapy indicated Yes No antihypertensive Prehypertension 120-139 or 80-89 drug therapy indicated Yes Thiazide-type diuretic Hypertension, 140-159 or 90-99 and consider other Stage 1 meds Hypertension, Yes Two-drug combination >160 or ≥100 Stage 2 for most

When treating hypertension in people with diabetes, the American Heart Association and the Joint National Committee Report on the Treatment of High Blood Pressure recommend a goal blood pressure <130/80 mm Hg. Recent evidence from the ACCORD blood pressure trial indicated that intensive blood pressure control (<120 mm Hg) should not be used in high-risk patients with diabetes because of greater risk of adverse events.24

16 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Follow-Up Recommendations Based on Initial BP Measures23 d h D S Ty cr y y iag p s p e 2 l e een no Table 10: Follow-up Recommendations Based on Initial BP Measures ipid rt dia sis en Tlab e 10 i Follow-up Recommendations Based on Initial BP Measures n

e g si mia be of

a on t Classification Follow-up Recommendation n e d s a , Normal Recheck in 2 years n d Pre-Hypertension Recheck in 1 year Stage 1 Hypertension Re-evaluate within 2 months Stage 2 Hypertension Evaluate or refer for follow-up care within 1 month. If > 180/110, see physician immediately.

Dyslipidemia Screening and Diagnosis Criteria Most people are asymptomatic, but dyslipidemia can lead to symptomatic vascular disease which includes coronary and peripheral artery disease. In some cases, elevated lipid levels can cause xanthelasma (lipid deposits) on the eyelids, arcus senillis and xanthomas (e.g. tendons, joints).31 Screening for Dyslipidemia25,26 Early screening and identification of individuals with high cholesterol levels are critical to preventing the development of cardiovascular disease. The National Heart Lung and Blood Institute recommends that adults over 20 years old should be screened at least once every 5 years to assess individual risk for high cholesterol. The American Diabetes Association recommends screening for lipid disorders at least annually in diabetic patients, and more often if needed to achieve goals.9 The basic assessment should include taking a medical history and conducting a physical examination to evaluate the presence of major and modifiable risk factors, including:

Table Tl11:ab eMajor 11 Major and andModifiable Modifiable Risk RiskFactors Factors

Age (men ≥ 45 years, women ≥ 55 Hypertension years) Low HDL cholesterol values Cigarette smoking Polycystic Ovary Disease Ethnic groups Advanced age Family history of CVD/HTN/DIABETES Sedentary Lifestyle

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 17 Classification of Lipid Profile The baseline patient assessment should also involve determining and classifying cholesterol levels using a fasting lipid profile test to evaluate LDL cholesterol, HDL cholesterol, triglycerides and total cholesterol levels.

Table 12: Classification of Lipid Profile Risk Tlab e 12 Classification of Lipid Profile Risk LDL Cholesterol – Primary Target of Therapy (mg/dL) <100 (optional goal <70) Optimal 100-129 Near Optimal/above optimal 130-159 Borderline High 160-189 High ≥190 Very High Total Cholesterol (mg/dL) <200 Desirable 200-239 Borderline High ≥240 High HDL Cholesterol (mg/dL) < 40 men Low < 50 women ≥60 High (considered protective against heart disease) Triglycerides (mg/dL) < 150 Normal 150-199 Borderline High 200-499 High ≥500 Very High

Additional testing may be necessary to evaluate and treat the presence of cardiovascular disease.

18 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Comprehensive 3 Management of Type 2 Diabetes Diabetes Care Guidelines/Flow Sheet Achieving Glycemic Control • A1c Recommendations • Blood Glucose Level Goals • Recommended Blood Glucose Treatment Goals • Monitoring Blood Glucose Levels • Proper Disposal of Syringes and Needles • Patient Logs and Worksheets • Pharmacotherapy for Diabetes • Hypoglycemia Clinical Management of Hypertension • Target Blood Pressures and Self Measurement • Hypertension Treatment Algorithm, Initial Drug Choices • Pharmacotherapy for Hypertension • JNC 7 Reference Card Clinical Management of Dyslipidemia • Target Adult Cholesterol Levels • Classification of Lipid Profile • Pharmacotherapy for Dyslipidemia • ATP III At-A-Glance: Quick Desk Reference Lifestyle Interventions and Modifications • Recommended Lifestyle Modifications • Weight Loss/Maintenance • Medical Nutrition Therapy (MNT) • General Nutritional Recommendations for Diabetes o Nutritional Recommendations for Weight Loss In Diabetes o Physical Activity and Exercise In Diabetes

While achieving glycemic control early in the course of the disease is critical to reducing serious long term complications, so is having good control of lipids and blood pressure. Unfortunately, many people with diabetes struggle with achieving target control levels of this clinical triad. Comprehensive management of diabetes means addressing the management of blood glucose, blood pressure and lipids for all patients with diabetes to reduce the risk of common comorbidities such as heart attack, congestive heart failure and chronic kidney disease.8

This approach is supported by recently released guidelines of the American Association of Clinical Endocrinology, which also emphasize a personalized approach to care that includes consideration of patient risk factors, comorbid conditions, expected life span, and psychological, social and economic status.

Diabetes Care Guidelines/Flow Sheet2,9 Individuals with diabetes should receive regular office visit exams and tests according to the following schedule:

20 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 13 Diabetes Care Guidelines/Flow Sheet Diabetes Care Guidelines/Flow Sheet

Name ______MR # ______D.O.B. ______Language______Race/Ethnicity ______

Clinical Parameters Frequency Goal/ Recommendation Date/ Date/ Date/ Date/ Priorities Results: Results: Results: Results:

History, Blood Pressure Every Visit <130/80 mm/Hg

Physical 2 and Weight Every Visit BMI <25 kg/m ; reduce weight by 5%-10% if overweight Emotional Foot exam Every Visit Inspect skin; teach protective foot behavior if sensation diminished Ty ma Co p mpr Foot exam-monofilament Annually Prevention of ulceration and amputations n e 2 ag e dia e h Dilated Eye Exam Annually Retinopathy prevention m en en be

Dental Bi-Annually Assess oral symptoms/ refer to dentist si

t of e ve Depression Annually Assess for mood disorders; suggest support groups/counsel/referral s Medication Review Every visit Optimize glycemic control and for the primary or secondary (diabetes meds, statin, prevention of CVD and/or management of HTN and ACE/ARB and/or aspirin) hyperlipidemia; reconcile medication list; discuss adherence issues Tobacco Status: ______Never ______Former______Current Quit Date: ______If current smoker, refer to California Smokers’ Helpline at 1-800-NO-BUTTS General Periodic H&P/ Pap or As indicated Early detection of cervical and prostate cancer Care Prostate Mammogram/ Chest X- Every 1 - 2 Early detection of breast cancer; screening to begin at age 40 or 50† Ray years Colorectal Cancer After age 50 Early identification of colorectal cancer

EKG As indicated Detection of cardiac abnormalities Lab A1C Quarterly <7% for most patients* Albumin/Creatinine Ratio Annually Check spot urine for albumin and creatinine, calculate ratio ≥ 30 µg alb/mg creatinine is abnormal Serum Creatinine for Annually Estimate glomerular filtration rate (GFR) to stage the level of eGFR chronic kidney disease (CKD) LDL Annually < 100 mg/dL; <70 mg/dL (optional goal) Triglycerides Annually <150 mg/dL HDL Annually >40 mg/dL in men; > 50 mg/dL in women Non-HDL Annually <130 mg/dL; <100 mg/dL (optional goal) Total Cholesterol Annually < 200 mg/dL Vaccine Flu Vaccine Encourage vaccination annually upon availability of vaccine Pneumovax Revaccinate >65 years old if initial vaccine given >5 years ago and < 65 years old Tetanus/ PPD Vaccination against tetanus; determine exposure to TB Tdap/ Pertussis Vaccination against tetanus, diphtheria & pertussis

Self Management Goals Patient Goals Self-Glucose Monitoring Pt. to monitor glucose as necessary to minimize risk of hyper/hypo glycemic episodes; review and check patient log book for accuracy Physical Activity 150 minutes of moderate to vigorous exercise a week Nutrition Advise weight reduction if BMI ≥25; refer to dietician/MNT Foot Exam Review foot inspection instructions with patient Medication Management/Adherence Discuss barriers/solutions to adherence; reconcile medication list † For women at average risk of breast cancer, the US Preventive Services Task Force recommends mammograms every 2 years beginning at age 50 while the American Cancer Society recommends yearly mammograms beginning at age 40. * More or less stringent A1c values may be appropriate dependent on individual history, risk factors and length of disease, among other considerations. Sources: American Diabetes Association, Standards of Medical Care in Diabetes, 2011 and the American Association of Clinical Endocrinologists Medical Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan, 2011 Notes: 1) Any application of these recommendations should be made in consideration of the needs, conditions and circumstances of each individual patient. 2) This flow sheet is included in the CMA Foundation’s Diabetes and Cardiovascular Disease Provider Reference Guide (2nd ed.), 2011

A1c Recommendations

Studies have demonstrated that A1c is a strong predictor of future diabetes complications. Recent studies confirm that the A1c closely represents the average glucose over the last 3 months. The table below correlates A1c with estimated average glucose. A calculator can be used to covert A1c results into estimated average glucose (eAG) at http://professional.diabetes.org/ GlucoseCalculator.aspx.

Note that the A1c can be affected by conditions that affect red blood cell turnover (such as anemia and hemoglobinopathies like sickle cell disease), which needs to taken into consideration especially when the A1c result does not correlate with the patient’s clinical situation or home monitored glucose levels.

Table 14: Tl Correlationab e 14 Correlation of A1c to meanof A1c Blood to Mean Glucose Blood Values Glucose Values

A1c % estimated Average Glucose (eAG) mg/dL 6 126 7 154 8 183 9 212 10 240 11 269 12 298

The American Diabetes Association recommends that patients have A1c done at least every 6 months if they have stable glucose levels that are at goal, and every 3 months in patients who are not at goal or who are changing therapy.

Blood Glucose Level Goals

The A1c goal for most adult patients with diabetes should be < 7.0%, in order to decrease the long term risk of complications.

Some patients with long life expectancy, and no significant CVD may benefit from an even lower A1c goal (such as < 6.5%) due to evidence of a small incremental improvement of microvascular outcomes.8

22 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 TableTl 15ab: eRecommended 15 Recommended Blood BloodGlucose Glucose Treatment Treatment Goals Goals

HgA1c <7 7% % FPG/Preprandial (before meals) 70-130 mg/dl

Peak postprandial (1-2 hours < 180 mg/dl after meals)

Difference between preprandial < 30-50 mg/dl and 1-2 hour postprandial Ty ma Co p mpr n e 2 * Note: higher or lower goals may be appropriate for individual ag e patients. Goals should be individualized based on duration of dia e h m en

en diabetes, age/life expectancy, comorbid conditions, known CVD or be si t advanced microvascular complications, hypoglycemia unawareness, t of e ve

individual patient considerations. s

Monitoring Blood Glucose Levels

Keeping blood glucose levels within a normal range is the principal goal of having patients check their blood sugar levels on a daily basis using a home meter. Patients who benefit should be encouraged to use their home glucose meters as a self-management tool to help them keep adequate control over sugar levels and minimize the risk of disease-related complications.

There are many different types of blood glucose monitoring devices available on the market today. Consider the following tips when discussing glucometer options. • In most cases, the meter options and decision about what meter to use will be affected by insurance coverage. Patients should be advised to contact their health plan to find out what materials and supplies are covered. • Patients need to understand how to use their meter. They should be trained before leaving the office or referred to a certified diabetes educator for full instruction. They should also be referred to the glucometer’s website for further information. In addition, some pharmacists are able to provide point of service training on how to use personal blood glucose meters • Recommend keeping logs or a diary of blood glucose results to be reviewed at the next visit. • Patients should bring their personal meters and log books with them to every office visit.

While regular monitoring of blood glucose values takes commitment on the patient’s part and is expensive, testing can help patients identify patterns, respond quickly to high or low blood sugar levels, learn how food and exercise affects sugar levels, and make appropriate lifestyle adjustments to achieve better control.

Examples of common blood glucose testing times: • Immediately after waking up • Before meals • 1 to 2 hours after meals • Before and after exercising • Before driving a vehicle • At bedtime • As necessary during the night • More frequently during illness or stress (4-6 hours)

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 23 Notes: • Patients on multiple daily doses of insulin should generally check at least 3-4 times per day. • Patients who are not on insulin may consider choosing an occasional meal and check both before and 1-2 hours after that meal, to see how the content of the meal affects the glucose levels.

Recommend immediate checking of blood sugar levels using a personal meter if the patient thinks their blood sugar is low or they experience any of the following signs: • Weakness • Fatigue • Dizziness or shakiness • Excessive sweating • Fast heart rate • Headache • Hunger • Nervousness or irritability • Blurred vision

Common patient barriers to using personal blood glucose meters and routine monitoring include:

• Test strips can be expensive. Some insurance providers limit the number of strips patients can purchase each month. • Need to have testing supplies on hand. • Testing can be inconvenient and interrupt daily activities. • Fingersticks can cause pain and discomfort. (Many meters can be used painlessly in alternate sites. Patients should check their glucometer instruction manual.) • Monitoring is a constant reminder of the diagnosis. • Fear that elevated results mean their diabetes is worse or insulin is needed. • Belief that results place judgment on self-management efforts.

24 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Proper Disposal of Syringes and Needles

On September 1, 2008 a new California law went into effect prohibiting the disposal of home generated sharps waste in California residents’ trash or recycling containers and requiring that all such waste be transported to a collection center in an approved sharps container. This includes needles, pen needles, intravenous needles, lancets and other devices that are used to penetrate the skin for medication administration.27

Table 16: Household Sharps Waste Disposal Options Tlab e 16 Household Sharps Waste Disposal Options Ty ma Co

p mpr n e 2 Collection programs ag e dia e h m

Some drug stores take back their customers’ needles, especially in small en en Pharmacies be si

quantities t t of e ve Hospitals may take back sharps from patients using regular outpatient s Hospitals services

Local Household Call your local household hazardous waste agency and ask if they collect Hazardous Waste needles (sharps) at their collection facilities or on household hazardous Programs waste days

A list of sharps waste mail-back services authorized for use in California is available from the California Department Of Public Health (CDPH) at Mail-Back Service http://www.cdph.ca.gov/certlic/medicalwaste/Pages/MailBackSharps.aspx

Your local white pages’ government section may list your city’s or county’s household hazardous waste department

Visit the Earth 911.org at http://earth911.com/website or call 1-800- CLEANUP (1-800-253-2687), a service of Earth 911 You can also look for this information here Visit the Local Enforcement Agency Directory at http://www.calrecycle.ca.gov/LEA/Directory/default.asp

Sharps and Medication Disposal Directory at http://www.calrecycle.ca.gov/HomeHazWaste/HealthCare/Collection

Local Jurisdiction Sharps Collection Programs at Local jurisdictions’ http://www.calrecycle.ca.gov/HomeHazWaste/Sharps/LocatorProgrm.pdf sharps collection This spreadsheet could help jurisdictions that don’t currently have programs collection programs to set up their own sharps collection program

Needle Destruction Devices. The U.S. Food and Drug Administration (FDA) currently only lists the “Disintegrator” as a needle destruction device approved for use by self-injectors.

Sharps Containers. The California Department of Public Health Medical Waste Management Program is recommending the use of sharps containers approved by the FDA. After accessing the FDA website, type “sharps” in the search box. The container names will display alphabetically.

Listserv: To receive periodic information about sharps, subscribe to the Sharps and Medication Disposal Listserv.

Contact: Please contact [email protected] for questions or more information.

Patient blood glucose daily logs, diabetes health records and healthy goal worksheets are helpful tools that promote better self-management and increase medication adherence by reminding patients to check their blood glucose levels and track daily activities. Many logs and worksheets also contain simple tools and tips to help patients adhere to recommended therapies and promote making lifestyle changes necessary to manage their type 2 diabetes. Such logs and worksheets can help guide health care providers by patient discussions, support adjustments to prescribed therapies and educate patients about type 2 diabetes and the importance of effective self- management.

See the Patient Resources section Chapter 6, page 95 of this reference guide for a selection of sample logs, goal worksheets and more.

Pharmacotherapy for Diabetes28,29

The clinical approach to managing diabetes starts with lifestyle/behavior modification, weight loss, physical activity promotion, and dietary control (see page 56). However, most patients with type 2 diabetes will also need oral or insulin medications to help achieve glycemic control. Healthcare providers should take into consideration any individual patient cardiovascular risk factors and the potential impact of side effects including fluid retention and weight gain when prescribing oral and injectable diabetes medications. Of note, diabetes progresses over time, requiring adjustments to the medication regimen.

Often using multiple drugs is necessary to achieve adequate glycemic control and reduce the risk of co-morbid cardiovascular disease and complications. In some cases, the use of combination drugs can help to simplify patient drug regimens and hopefully lead to better compliance or fewer copays.

The following tables highlight common oral and injectable medications used to treat and manage diabetes.

26 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 17 Oral Medications

Drug class Generic name Brand name(s) Mechanism of action Potential side effects Biguanides Metformin Fortamet Inhibits liver Cramping, nausea, Glucophage glucose diarrhea, vomiting, Glucophage XR production, gas, loss of appetite, Glumetza q muscle glucose metallic taste Riomet uptake

Sulfonylureas q

Glimepiride Amaryl pancreatic Hypoglycemia, GI Ty ma Co p

insulin mpr

upset, weight gain n e 2 production (note: avoid ag e dia e h glyburide in elderly m en en

Glipizide Glipezide ER be

and those with renal si t t

Glipezide XL of e ve

insufficiency due s Glucotrol to increased risk of Glucotrol XL hypoglycemia in this Glyburide Diabeta population.) Glynase Micronase Glycron

Meglitinides Repaglinide Prandin q insulin released Hypoglycemia, from pancreas weight gain, joint pain Nateglinide Starlix Thiazolidinediones Pioglitazone Actos q skeletal muscles Hypoglycemia, (TZDs) glucose uptake edema, headache, Rosiglitazone** Avandia **Restricted use by mild anemia, weight FDA due to possible gain, muscle pain, increased CV risk (only URI, sinusitis use if unable to use other options.) Alpha-glucosidase Acarbose Precose Inhibits Cramping, diarrhea, inhibitors carbohydrate gas, GI upset/pain, absorption by weight loss. the small intestine Need to treat hypoglycemia with glucose Bile acid sequestrant Colesevelam Welchol Lipid t polymer Constipation, hydocloride that binds bile nasopharyngitis, acids in the dyspepsia, intestine, t hypoglycemia, reabsorption. nausea, hypertension The exact A1c t action is currently unknown.

Dipeptidyl Sitagliptin Januvia Enzyme inhibitor, Runny/stuffy peptidase-4 suppresses nose, sore throat, (DPP-4) inhibitor release of headache, stomach glucagon by pain, diarrhea pancreas Saxagliptin Onglyza Upper respiratory tract infection, urinary tract infection, headache Linagiptin Tradjenta t blood sugar by Upper respiratory q incretin levels infection, stuffy or runny nose, sore throat, muscle pain, headache

Combination drugs Metformin HCL/ Glucovance See mechanism See side effects for glyburid, Micro of action for each drug in the Glyburide, Glycron each drug in the combination, listed Micronized Glynase combination, separately above. listed separately Metformin/ Metaglip above. glipizide Metformin HCL Actopuls Met /Pioglitazone HCL Metformin/ Janumet Sitagliptin Glimepiride / Duetact Pioglitazone Glimepiride/ Avadaryl Rosiglitazone Rosiglitazone/ Avandamet Metformin HCL Repaglinide/ Prandimet Metformin HCL Saxagliptin/ Kombiglyze XR Metformin

28 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 18 Non-Insulin Injectables Drug class Generic name Brand name Mechanism of action Potential side effects Amylin analog Pramlintide Symlin Synthetic amyin Nausea; decrease emptying sugar which aids in appetit, vomiting, the absorption dizziness, indigestion of glucose by and stomach pain. slowing stomach Hypoglycemia when emptying, used with insulin promoting fullness, and preventing Ty ma Co p mpr n e 2

secretion of ag e glucagon from the dia e h m en en liver. be si t t of e q ve Incretin mimetics Exenatide Byetta insulin secretion Headache, nausea s in the presence of and vomiting, elevated plasma (titration dependent) glucose levels diarrhea, dizziness, possible increased risk of pancreatitis Liraglutide Victoza q insulin secretion (Victoza: watch for thyroid cancer due in the presence of to increased risk in elevated plasma animal models) glucose levels, and delays gastric emptying.

Insulin Guidelines

Consider using the Diabetes Coalition of California (DCC) insulin guidelines when starting and titrating insulin in patients with type 2 diabetes. For additional information, please visit the DCC’s website at www.diabetescoalitionofcalifornia.org.

Diabetes Coalition of California Type 2 Diabetes Adult Outpatient Insulin Guidelines

This product may be reproduced with the citation: “Developed by the Diabetes Coalition of California, October 2010” See Web site (www.diabetescoalitionofcalifornia.org) for the latest version and disclaimer. Page 1 of 5

30 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes Coalition of California Type 2 Diabetes Adult Outpatient Insulin Guidelines Ty ma Co p mpr n e 2 ag dia e e m h en en be si t t of e ve s

32 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Ty ma Co p mpr n e 2 ag e dia e h m en en be si t t of e ve s

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 33 34 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 20 Insulin Injectables

Drug class Generic name Brand Onset Peak Duration Comments name Rapid-acting Lispro Humalog 5-15 min 30-90 < 5 hr Clear min Aspart Novolog 5-15 min 30-90 < 5 hr min Ty ma Co

Glulisine Apidra 5-15 min 30-90 < 5 hr p mpr n e 2 min ag e dia e h Short acting m en

Regular (R) Human 30-60 min 2-3 hr 5-8 hr Clear en be si t t of

Intermediate e NPH (N) Human 2-4 hr 4-10 hr 10-16 hr Cloudy ve acting s

Long acting Detemir Levemir 3-8 hr 3-4 hr 6-24 hr, Clear, (50%) dose typically No peak dependent taken once daily (example Glargine Lantus 2-4 hr No peak 20-24 hr before evening meals or at bedtime). Helps prevent high morning blood glucose values.

Premixed – 75% insulin Humalog 5-15 min Dual 10-16 hr Cloudy human lispro protamine Mix 75/25 suspension/ 25% insulin lispro

50% insulin Humalog 5-15 min Dual 10-16 hr lispro protamine Mix 50/50 suspension/ 50% insulin lispro 70% insulin NovoLog 5-15 min Dual 10-16 hr aspart protamine Mix 70/30 suspension/ 30% insulin aspart 70% NPH/ 30% 70% NPH/ 30-60 min Dual 10-16 hr regular 30% regular

Note: Nausea and vomiting can be lessened or avoided with dose titration.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 35 Hypoglycemia There are many drugs including oral diabetes medication and insulin that can decrease blood sugar levels, resulting in increased risk for hypoglycemic events. The risk of experiencing drug interactions and negative side effects relative to the expected benefits should be discussed with the patient when deciding medication regimens to treat and control diabetes.

In particular, beta blockers are known to have adverse interactions with insulin by masking the signs and symptoms of hypoglycemia. In some cases beta blockers can also increase overall chances of developing high blood sugar.

Clinical Management of Hypertension23

The National Heart Lung and Blood Institute (NHLBI), JNC-7 guidelines recommend that patients with hypertension receive interventional therapies that include a combination of lifestyle modifications (see Chapter 5, page 79) and pharmacologic therapies to reach target blood pressure values and decrease long term cardiovascular risk. JNC-7 emphasizes that adoption of healthy lifestyles by individuals with high blood pressure is critical to preventing and lowering blood pressure and overall body weight. See JNC-7 Reference Cards, pages 43-44.

Target Blood Pressures and Self Measurement By treating hypertension to reach target blood pressure values, the risk of developing cardiovascular complications and mortality is greatly reduced. The NHLBI recommends the following target blood pressures for individuals with and without related complications:

TableTl 21:ab eTarget 21 Target Blood Blood Pressure Pressure

With hypertension, no additional compelling Less Than 140/90 mm Hg conditions

For patients with diabetes or chronic kidney Less Than 130/80 mm Hg disease

Optimal (Normal) Less Than 120/80 mm Hg

Patients with high blood pressure should be advised to self monitor at home and work, as a practical approach to understanding and managing this chronic disease. Self measurements are also useful in assessing the difference between home and in medical office values commonly associated with white coat hypertension, also referred to as white coat syndrome. Monitoring through self measurement will help patients reach target blood pressure values by offering further insight into the effect of medically supervised management strategies on blood pressure control.

Hypertension Treatment Algorithm, Initial Drug Choices In addition to lifestyle modifications highlighted in the JNC-7 guidelines, initial hypertensive therapies may require the use of medications to reach goal. Most patients frequently require a combination of medications from different antihypertensive drug classes when a single medication fails to achieve adequate control of blood pressures.

36 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Achieving Blood Pressure Control in Individual Patients

Most patients who are hypertensive will require two or more antihypertensive medications to achieve their BP goals.14,15 Addition of a second drug from a different class should be initiated when use of a single drug in adequate doses fails to achieve the BP goal. When BP is more than 20/10 mmHg above goal, consideration should be given to initiating therapy with two drugs, either as separate prescriptions or in fixed-dose combinations. (See figure 1.) The initiation of drug therapy with more than one agent may increase the likelihood of achieving the BP goal in a more timely fashion, but particular caution is advised in those at risk for orthostatic hypotension, such as patients with diabetes, autonomic dysfunction, and some older persons. Use of generic drugs or combination drugs should be considered to reduce prescription costs.

Figure 3 Algorithm for Treatment of Hypertension Figure 1. Algorithm for treatment of hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for patients with diabetes or chronic kidney disease) Ty ma Co p mpr n e 2 ag e dia e h m en en be si t Initial Drug Choices t of e ve s

Without Compelling With Compelling Indications Indications

Stage 1 Stage 2 Drug(s) for the Hypertension Hypertension compelling indications (SBP 140–159 or DBP (SBP ≥160 or DBP (See table 8) 90–99 mmHg) ≥100 mmHg) Other antihypertensive Thiazide-type diuretics Two-drug combination for drugs (diuretics, ACEI, for most. May consider most (usually thiazide- ARB, BB, CCB) as needed. ACEI, ARB, BB, CCB, type diuretic and ACEI, or combination. or ARB, or BB, or CCB).

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

DBP, diastolic blood pressure; SBP, systolic blood pressure. Drug abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta-blocker; CCB, calcium channel blocker. 13

*Source: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute, August 2004.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 37 Pharmacotherapy for Hypertension23 Today there are number of commonly used antihypertensive medications in different drug classes. Many patients with hypertension may require two or more antihypertensive medications from different drug classes and in combination to reach goal.

Thiazide diuretics are considered the initial therapy for hypertension in most patients and can be useful in helping to achieve control of elevated blood pressure levels. Thiazide may be used as a stand-alone agent or in combination with other drug classes

Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are also considered ideal medications for the treatment of patients with diabetes and hypertension. Both ACE and ARBs inhibitors provide positive effects on renal function and may result in improved insulin sensitivity.30

A patient receiving drug therapy for hypertension should receive regular and routine follow-up to adjustment medications as necessary to reach target blood pressure measurements and prevent cardiovascular complications. Patients with related co-morbidities including heart failure and diabetes may require more frequent office visits and lab testing to reach goal.

The following tables list commonly used antihypertension medications. There are currently six commonly used classes of medications used to treat hypertension:

• ACE Inhibitors • ARBs (angiotensin II receptor antagonists) • Calcium channel blockers • Thiazide diuretics • Beta blockers • Alpha blockers or alpha-adrenergic blockers

38 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 22 Oral Blood Pressure Lowering Medications Drug class/category Generic name Brand name(s) Mechanism of Common side action effects Angiotensin- Benazepril Lotensin Prevents the Cough, elevated Converting Enzyme formation of potassium (ACE) Inhibitors Captopril Capoten angiotensin II levels, low blood pressure, Enalapril Vasotec dizziness, Vasotec IV headache,

drowsiness, Ty ma Co p mpr n

weakness, e 2 Fosinopril Monopril ag e abnormal taste, dia e h m

Lisinopril Prinivil en en

rash be si t Zestril t of e ve s Moexipril Univasc Perindopril Aceon Quinapril Accupril Ramipril Altace Trandolapril Mavik Angiotensin II Candesartan Atacand Prevents the Cough, elevated Receptor Blockers interaction of blood potassium (ARBs) Eprosartan Teveten angiotensin levels, low II with tissue blood pressure, Irbesartan Avapro receptors dizziness, Losartan Cozaar headache, Olmesartan Benicar drowsiness, diarrhea, Telmisartan Micardis abnormal taste, Valsartan Diovan rash Calcium Channel Amlodipine Norvasc Blocks calcium Constipation, Blockers, channels in nausea, Felodipine Plendil Dihydropyridines muscle cells of headache, rash, Isradipine DynaCirc the heart and edema, low DynaCirc CR blood vessels blood pressure, drowsiness, Nicardipine Cardene dizziness, Cardene SR difficulty Cardene IV breathing, wheezing Nifedipine Adalat Adalat CC Afeditab CR Nifedical XL Procardia Procardia XL Nisoldipine Sular

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 39 Tlab e 22 Oral Blood Pressure Lowering Medications Drug class/category Generic name Brand name(s) Mechanism of Common side action effects Calcium Channel Diltiazem Cardizem Blocks calcium Constipation, Blockers, Non- Cardizem CD channels in nausea, Dihydropyridines Cardizem LA muscle cells of headache, rash, Cardizem SR the heart and edema, low Cartia XT blood vessels blood pressure, Dilacor XR drowsiness, Diltia XT dizziness, Nu-Diltiaz difficulty Taztia XT breathing, Tiazac wheezing Verapamil Apo-Verap Calan Calan SR Covera-HS Isoptin Isoptin SR Verelan Verelan PM Thiazide diuretics Chlorothiazide Diuril Inhibits sodium Dizziness, Chlorthalidone Hygroton and chloride lightheadedness, Thalitone reabsorption blurred vision, from the distal loss of appetite, Hydrochlorothiazide Esedrix convoluted itching, stomach HCTZ tubules in the upset, headache, Hydro-chlor kidneys weakness, rash, Hydro-D gout, muscle HydroDIURIL Microzide pain, Novo- Hydrazide Oretic Polythiazide Renese Indapamide Lozol Metolazone Zaroxolyn Loop diuretics Bumetanide Bumex Inhibits sodium and chloride Furosemide Lasix reabsorption Torsemide Demadex from the loop of Henle in the Ethacrynic Acid Edecrin kidneys Potassium sparing Amiloride Midamor Prevents sodium diuretics reabsorption without lower Triamterene Dyrenium potassium levels

40 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 22 Oral Blood Pressure Lowering Medications

Drug class/category Generic name Brand name(s) Mechanism of Common side action effects Aldosterone receptor Eplerenone Inspra Blocks the action Cough, diarrhea, blockers flu like symptoms, Spironolactone Aldactone of aldosterone headache, stomach pain

Beta blockers Atenolol Tenormin Blocks the Dizziness, Ty ma Co p mpr n e 2 Betaxolol Kerlone action of lightheadedness, ag e dia e h epinephrine and drowsiness, m en en Bisoprolol Monocor Zibeta norepinephrine blurred vision, be si t t of e ve

Metoprolol Lopressor on B-adrenergic rash, itching, s Extended Toprol-XL receptors swelling Nadolol Corgard Propranolol Inderal Inderal LA InnoPran XL Timolol Blocadren Beta blockers Acebutolol Sectral Exerts low level w/ intrinsic agonist activity sympathomimetic at B-adrenergic Penbutolol Levatol activity receptors site while acting as Pindolol Visken a receptor site antagonist

Alpha-blockers Doxazosin Cardura Inhibits the alpha Dizziness, 1 adrenergic lightheadedness, nervous system, drowsiness, Prazosin Minipress causing muscle headache, relaxation and constipation, dilation of blood loss of appetite, vessels dry mouth, stuffy Terazosin Hytrin nose, blurred vision, trouble sleeping

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 41 Tlab e 22 Oral Blood Pressure Lowering Medications Drug class/category Generic name Brand name(s) Mechanism of Common side action effects Combined Alpha & Carvedilol Coreg Blocks alpha-, Dizziness, fatigue, Beta blockers Coreg CR beta1-, and headache, diarrhea, beta2-adrenergic edema, dry eyes, receptor sites scalp/skin tingling Labetalol Normodyne Dizziness, fatigue, Trandate headache, diarrhea, edema, dry eyes, scalp/skin tingling

Direct Hydralazine Apresoline Smooth muscle Skin Irritation, vasodilators relaxant, causing itching, contact arterial dilation dermatitis, hives, Minoxidil Loniten swelling and sensitivity

Central alpha agonists Clonidine Catapres Centrally acting Dizziness, Clonidine patch Catapres-TTS alpha-adrenergic lightheadedness, Duracion agonist drowsiness, Methyldopa Aldomet dry mouth, constipation Reserpine Novoreserpine Reserfia Guanfacine Tenex

42 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Indications ith Compelling Compelling W B, BB, CCB) as needed. Drug(s) for the compelling indications See Indications for Individual Drug Classes Other antihypertensive drugs (diuretics, ACEI, AR Ty ma Co evention, p mpr n e 2 140/90 mmHg) ag < e dia e h m en en be si t t of e ve s Initial Drug Choices ategies for Improving Adherence to Therapy to Adherence ategies for Improving ategies for Improving Adherence to Therapy to Adherence ategies for Improving r r Lifestyle Modifications St St Not at Goal Blood Pressure Blood Goal at Not See See Stage 2 Hypertension (SBP ≥160 or DBP ≥100 mmHg) 2-drug combination for most (usually thiazide- type diuretic and ACEI, or ARB, or BB, or CCB). Not at Goal Blood ( Pressure achieved. achieved. Consider consultation with hypertension specialist. Indications MENT 130/80 mmHg for patients with diabetes or chronic kidney disease) ithout Compelling < Optimize Optimize dosages or add additional drugs until goal blood pressure is ( W I, ARB, BB, CCB, reat to BP <140/90 mmHg or <130/80 in patients E T with diabetes or chronic kidney disease. Majority of patients will require two medications to reach goal. rinciples of Hypertension Treatment Hypertension of rinciples Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider AC or combination. • • P of Hypertension Treatment for Algorithm TREAT <80 ≥ 100 DBP mmHg Cushing’s syndrome or steroid Cushing’s therapy Pheochromocytoma Coarctation of aorta Thyroid/parathyroid disease Physical inactivity estimated Microalbuminuria, glomerular filtration rate <60 mL/min Age (>55 for men, >65 women) Family history of premature CVD (men age <55, women <65) • • • • • • • • ≥ 160 or <120 and (reverse side) (reverse 120–139 or 80–89 SBP mmHg ) 2 30 kg/m eference Card From the eference Card From R Seventh Report of the Joint National Committee on Pr of High Blood Pressure (JNCTreatment Detection, Evaluation, and 7) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OF HEALTH U.S. DEPARTMENT National Institutes of Health National Heart, Lung, and Blood Institute Blood Pressure Measurement Techniques Measurement Blood Pressure Assess risk factors and comorbidities. Reveal identifiable causes of hypertension. Assess presence of target organ damage. Conduct history and physical examination. Obtain laboratory tests: urinalysis, blood glucose, hematocrit and lipid panel, serum potassium, creatinine, and calcium. Optional: urinary albumin/creatinine ratio. Obtain electrocardiogram . Sleep apnea Drug induced/related Chronic kidney disease Primary aldosteronism Renovascular disease Hypertension Obesity (body mass index > Dyslipidemia Diabetes mellitus Cigarette smoking tegory * * See Key: SBPKey: = systolic blood pressure DBP = diastolic blood pressure Prehypertension Hypertension, Stage 1Hypertension, Stage 2 140–159 or 90–99 Normal • • • • • • • • • • • • • • • • Diagnostic Workup of Hypertension Workup Diagnostic Disease (CVD) Major Cardiovascular for Assess Risk Factors Hypertension of Causes Identifiable for Assess Classification of Blood Pressure (BP)* Pressure Blood of Classification Ca EVALUATION

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 43 † 5–20 mmHg/10 kg 8–14 mmHg 2–8 mmHg 4–9 mmHg 2–4 mmHg 1 drink* per day. 2 drinks* per day. day. per drinks* 2 ). 2 omen and lighter weight per- 100 mmol per day (2.4 g sodi- Adopt a diet rich in fruits, vegetables, and lowfat dairy products with reduced content of saturated and total fat. Reduce dietary sodium intake to < um or 6 g sodium chloride). Regular aerobic physical activity (e.g., brisk walking) at least 30 most days minutes per day, of the week. < to limit Men: W to < sons: limit Maintain normal body weight (body mass index 18.5–24.9 kg/m eight Encourage healthy lifestyles for all individuals. Prescribe lifestyle modifications for all patients with prehypertension and hypertension. Components of lifestyle modifications include weight reduction, DASH and eating plan, dietary sodium reduction, aerobic physical activity, moderation of alcohol consumption. rinciples of Lifestyle Modification rinciples W reduction DASH eating plan Dietary sodium reduction Aerobic physical activity Moderation of alcohol consumption • • • U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OF HEALTH U.S. DEPARTMENT National Institutes of Health National Heart, Lung, and Blood Institute Education Program National High Blood Pressure NIH Publication No. 03-5231 May 2003 Lifestyle Modification Recommendations Lifestyle Modification P * 1 drink = 1/2 oz or 15 mL ethanol (e.g., 512 oz beer, oz wine, 1.5 oz 80-proof whiskey). † Effects are dose and time dependent. Modification Recommendation SBP Avg. Reduction Range Initial Therapy Options Therapy Initial THIAZ, BB, ACEI, CCB THIAZ, BB, ACEI, ARB, CCB ACEI, ARB THIAZ, BB, ACEI, ARB, ALDO ANT or from the NHLBI Health Information Center, P.O. Box P.O. NHLBI Health Information Center, or from the o readings, 5 minutes apart, sitting in chair. Notes Tw Confirm elevated reading in contralateral arm. Indicated for evaluation of “white coat hypertension.” Absence of 10–20 percent BP decrease during sleep may indicate increased CVD risk. on response to therapy. Provides information May help improve adherence to therapy and is tension.” hyper coat “white evaluating for useful OTC) drugs and herbal supplements http://www.nhlbi.nih.gov Inadequate doses Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) ( Over-the-counter blocker, BB CCB = = beta blocker, ALDO calcium blocker, ANTchannel blocker, = aldosterone antagonist uses of Resistant Hypertension Resistant of uses rategies for Improving Adherence to Therapy to Adherence Improving for rategies mpelling Indication mpelling Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication – – – Excess alcohol intake Identifiable causes of hypertension (see reverse side) Clinician empathy increases patient trust, motivation, and adherence to therapy. Physicians should consider their patients’ cultural beliefs and individual attitudes in formulating therapy. Heart failure Post myocardial infarctionHigh CVD risk Diabetes Chronic kidney disease BB, ACEI, ALDO ANT Recurrent stroke prevention THIAZ, ACEI y: THIAZ = thiazide diuretic, ACEI= angiotensin convertingARB enzyme = inhibitor, angiotensin receptor • • • • • • • • Co • • • • • • In-office Ambulatory BP monitoring Patient self-check Ke St Ca Compelling indications for Individual Drug Classes Individual for indications Compelling Blood Pressure Measurement Techniques Measurement Pressure Blood Method 30105, Bethesda, MD 20824-0105; Phone: 301-592-8573 or 240-629-3255 (TTY); Fax: 301-592-8563. The National High Blood Pressure Education Program is coordinated by the National Heart, Lung, and Program is coordinated by the National Heart, The National High Blood Pressure Education are available on of the JNC 7 Report Blood Institute (NHLBI) at the National Institutes of Health. Copies at site the NHLBI Web

44 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Clinical Management of Dyslipidemia9,31,32,33

Addressing dyslipidemia is a key component in preventing long term cardiovascular disease in individuals with type 2 diabetes. Many patients with diabetes have elevated cholesterol values, which can lead to greater risk of developing cardiovascular disease or acute cardiovascular events. Diabetic dyslipidemia is a recognizable and modifiable patient risk factor that should be identified and treated early to prevent complications.

Published by the National Heart Lung and Blood Institute (NHLBI), the ATP III guidelines are an Ty ma Co p mpr

evidence-based set of recommendations that focus on intensive cholesterol-lowering therapy. The n e 2 guidelines address the primary prevention of coronary heart disease (CHD) in persons with multiple ag e dia e h m

risk factors by managing elevated patient cholesterol levels to reach goal. The ATP III Guidelines At- en en be si t

a-Glance Quick Desk Reference which outlines the step by step sequence of cholesterol management t of e ve has been provided. The NHLBI and the American Diabetes Association recommend prescribing s lifestyle modifications and cholesterol lowering medications to reach the following target (optimal) adult cholesterol levels:

Targeting Adult Cholesterol Levels

TableTlab 23:e 23Classification Classification ofof LipidLipid Profile Profile Risk

LDL Cholesterol – Primary Target of Therapy (mg/dL) <100 (optional goal <70) Optimal 100-129 Near Optimal/above optimal 130-159 Borderline High 160-189 High ≥190 Very High Total Cholesterol (mg/dL) <200 Desirable 200-239 Borderline High ≥240 High HDL Cholesterol (mg/dL) < 40 men Low < 50 women ≥60 High (considered protective against heart disease) Triglycerides (mg/dL) < 150 Normal 150-199 Borderline High 200-499 High ≥500 Very High

This table is also available in chapter 2, page 18.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 45 In addition to recommending primary preventive strategies that include therapeutic lifestyle modifications and lipid modifying medications, healthcare providers should evaluate patients for preventable secondary causes of dyslipidemia that include:

• Chronic renal failure • Diabetes • Hypothyroidism • Obstructive liver disease • Medications that affect LDL and HDL cholesterol levels, including: o Progestins o Corticosteroids o Anabolic steroids

There have been a number of recent clinical trials demonstrating that lowering LDL cholesterol levels using secondary prevention strategies can also help reduce the risk of developing major cardiovascular disease. Secondary prevention of dyslipidemia focuses on decreasing the overall risk of developing cardiovascular disease, acute coronary events, stroke, and mortality in people identified with chronic heart disease by lowering LDL cholesterol to a level less than 100 mg/dL by:34

• Increase or intensify lifestyle modifications • Recommend weight loss and increased physical activity for people with risk factors • Delay use or intensification of LDL lowering medication and institute treatment of other lipid or non-lipid risk factors • Consider use of other lipid modifying drugs to treat elevated triglyceride or low HDL cholesterol

Most lipid problems associated with a chronic illness are hereditary, and early consideration of lifelong medication management is important. Although lifestyle modification, diet and exercise are effective in combination with the use of pharmacotherapy, diet and exercise alone do not correct the underlying genetic disorder. Lowering LDL cholesterol levels through the use of secondary prevention strategies in combination with appropriate lifestyle modifications can greatly reduce an individual’s risk of developing diabetes related complications, experience cardiovascular events and premature mortality.

46 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Pharmacotherapy for Dyslipidemia23 To reach optimal lipid levels, most patients will require lipid modifying medications combined with Therapeutic Lifestyle Changes (TLC). While reducing serum LDL cholesterol is the primary target of treatment in clinical lipid management, some people may also benefit from therapies to lower triglycerides and/ or increase HDL cholesterol levels. Some individuals will require combined drug therapies to reach target treatment goals that result in a reduction of LDL cholesterol levels and, when advisable, raise HDL cholesterol levels.

Statins, also known as HMG-CoA reductase inhibitors, are currently considered the most Ty ma Co p mpr n e 2

effective, practical, and commonly prescribed class of drugs that target reducing LDL ag e cholesterol levels. The statins are generally well tolerated by most people and have a lower risk dia e h m en en of adverse side effects and/or risk of drug to drug interactions. be si t t of e ve s In some cases, drug therapies may need to be tailored to address specific dyslipidemias, including very high LDL cholesterol, elevated serum triglycerides, low HDL cholesterol and atherogenic dyslipidemia in persons with type 2 diabetes. Consideration should also be given to prescribing drug therapies that target both lipid and non-lipid causes of metabolic syndrome and insulin resistance.

There are several classes of lipid modifying and LDL lowering medications available to treat dyslipidemia, including:

• Statins (HMG-CoA reductase inhibitors) • Cholesterol absorption inhibitors • Niacin (nicotinic acid) • Fibric acid derivatives • Bile acid sequestrants • Combination drugs

Currently only nicotinic acid (niacin) has been approved for over the counter (OTC) use. The following table lists commonly used dyslipidemia treatment medications.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 47 tq

Tlab e 24 Dyslipidemia Treatment Medications69

Drug class/ Generic name Brand name(s) Mechanism of Potential side effects category action Statins (HMG- Atorvastatin Calcium Lipitor Inhibits HMG- Headache, CoA Reductase CoA reductase, nausea, vomiting, Inhibitors) causing a slow constipation, Fluvastatin Sodium Lescol down in the diarrhea, rash, Lescol XL production of weakness, cholesterol and muscle pain, Lovastatin Alctocor q the removal of rhabdomyolysis Altoprev LDL-cholesterol Mevacor by the liver Pravastatin Sodium Pravachol Rosuvastatin Sodium Crestor Simvastatin Zocor Pitavastatin Livalo Cholesterol Ezetimibe Zetia Inhibits intestinal Diarrhea, Absorption cholesterol abdominal pain, inhibitors absorption and back pain, joint reduces liver pain, sinusitis, cholesterol stores allergic reactions Niacin Nicotinic acid Endur-Acin Inhibits fatty acid Stomach (Nicotinic Acid) Nia-Bid release from upset, flushing, Niac adipose tissue headache, allergic Nacels and inhibits liver reactions Niacor production of Niaspan fatty acids and Nicobid triglycerides; Nico-400 q HDL levels, Nicolar t triglycerides and Nicotinex LDL cholesterol Nicotinic Acid Slo-Niacin Vitamin B

48 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tlab e 24 Dyslipidemia Treatment Medications69

Lipid Lovastatin/Niacin, Advicor t LDL cholesterol, See statin and combinations triglyceride, and niacin side effects total cholesterol levels, q HDL cholesterol Simvastatin/Niacin Simcor tTotal cholesterol Warmth, redness, – LDL and dizziness, Ty ma Co p mpr

triglycerides. sweating or n e 2 Slightly q HDL chills, headache, ag e dia e h m

stomach or back en en be si t ache, runny t of e ve nose or other s symptoms Simvastatin Vytorin t LDL cholesterol Headache, Ezetimibe nausea, vomiting, diarrhea, muscle pain, abnormal liver tests Amlodipine Caduet t LDL cholesterol Headache, Atorvastatin and triglycerides dizziness, in the blood, while drowsiness, q levels of HDL flushing, diarrhea, cholesterol abdominal pain, weakness, joint pain

Fibric acid Fenofibrate Antara, t Liver production Nausea, stomach derivatives Lipofen of VLDL and upset, diarrhea, Lofibra q triglyceride liver inflammation, Tricor blood formation of Triglide gallstones Trilipix

Gemifibrozil Lopid

Bile acid Cholestyramine, LoCHOLEST t LDL cholesterol Constipation, sequestrants Cholestyramine light LoCHOLEST by binding with abdominal Light cholesterol pain, bloating, Prevalite containing vomiting, Questran bile acids in diarrhea, Questran Light the intestines, weight loss and Cholestipol Cholestid eliminated in the flatulence stool Colesevelam WeChol

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 49 Hig h National Cholesterol Education Program ATP III Guidelines At-A-Glance Quick Desk Reference (NHLBI 2001 including updates from the NCEP Report 2004)

1 Determine lipoprotein levels–obtain complete lipoprotein profile after Step 1 9- to 12-hour fast.

ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL) Bl o

LDL Cholesterol – Primary Target of Therapy 01< 0 (optional goal: < 70)* lamitpO 921-001 raeN evoba/lamitpo lamitpo 951-031 enilredroB hgih 981-061 hgiH > 091 yreV hgih od Total Cholesterol 002< elbariseD 932-002 enilredroB hgih > 042 hgiH

HDL Cholesterol 04< woL > 06 hgiH Ch o

*An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available clinical trial evidence, for patients at very high risk. It does not apply to individuals who are not at high risk. Factors for very high risk include the presence of established CVD plus (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors of the metabolic syndrome (especially high triglycerides >=200 mg/dL plus non-HDL-C >=130 mg/dL with low HDL-C [<40 mg/dL]), and (4) on the basis of PROVE IT, patients with acute coronary syndromes. Grundy et al. (2004). Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 110: 227-239. 2 Identify presence of clinical atherosclerotic disease that confers high risk Step 2 for coronary heart disease (CHD) events (CHD risk equivalent):

I Clinical CHD les t I Symptomatic carotid artery disease I Peripheral arterial disease I Abdominal aortic aneurysm I Diabetes 3 Determine presence of major risk factors (other than LDL): Step 3 Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

Cigarette smoking er ol Hypertension (BP >140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL)* Family history of premature CHD (CHD in male rst degree relative <55 years; CHD in female rst degree relative <65 years) Age (men > 45 years; women > 55 years) * HDL cholesterol >60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

NA TIO N A L I N STITUTES OF HEALTH NA TIONAL HEAR T , LUNG, AND B LOO D INSTIT UTE

50 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 4 Step 4 If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk (see Framingham tables). Three levels of 10-year risk: I >20% — CHD risk equivalent I 10-20% I <10% Ty ma Co p mpr n e 2 5 ag e Step 5 Determine risk category: dia e h m en en I Establish LDL goal of therapy be si t I t Determine need for therapeutic lifestyle changes (TLC) of e ve I Determine level for drug consideration s

ATP III LDL-C Goals and Cutpoints for TLC and Drug Therapy in Di erent Risk Categories and Proposed Modications Based on Recent Clinical Trial Evidence (ATP III Update, NCEP Report, 2004)

yrogetaCksiR laoGC-LDL CLTetaitinI **yparehTgurDredisnoC High risk CHD* or CHD risk equivalents† 100 mg/dL 100 mg/dL# 100 mg/dL†† (10-year risk 20%) (optional goal: 70 mg/dL) ( 100 mg/dL: consider drug options)** Moderately high risk 2 risk factors‡ 130 mg/dL¶ 130 mg/dL# 130 mg/dL (10-year risk 10% to 20%) §§ (optional goal: 100 mg/dL) (100–129 mg/dL; consider drug options)‡‡ Moderate risk 2 risk factors‡ (10-year 130 mg/dL 130 mg/dL 160 mg/dL risk 10%)§§ Lower risk 0–1 risk factor§ 160 mg/dL 160 mg/dL 190 mg/dL (160–189 mg/dL: LDL-lowering drug optional) *CHD includes history of myocardial infarction, unstable angina, stable angina, coronary artery procedures (angioplasty or bypass surgery), or evidence of clinically significant myocardial ischemia. †CHD risk equivalents include clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease transient ischemic attacks or stroke of carotid origin or 50% obstruction ofacarotid artery ), diabetes, and 2 risk factors with 10-year risk for hard CHD 20%. ‡Risk factors include cigarette smoking, hypertension (BP 140/90 mm Hg or on antihypertensive medication), low HDL cholesterol ( 40 mg/dL), family history of premature CHD (CHD in male first-degree relative 55 years of age; CHD in female first-degree relative 65 years of age), and age (men 45 years; women 55 years). §§Electronic 10-year risk calculators are available at www.nhlbi.nih.gov/guidelines/cholesterol. §Almost all people with zero or 1 risk factor havea10-year risk 10%, and 10-year risk assessment in people with zero or 1 risk factor is thus not necessary. Very high risk favors the optional LDL-C goal of 70 mg/dL, and in patients with high triglycerides, non-HDL-C 100 mg/dL. ¶Optional LDL-C goal 100 mg/dL. #Any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) isacandidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level. **When LDL-lowering drug therapy is employed, it is advised that intensity of therapy be sufficient to achieve at leasta30% to 40% reduction in LDL-C levels. ††If baseline LDL-C is 100 mg/dL, institution of an LDL-lowering drug is a therapeutic option on the basis of available clinical trial results. Ifahigh-risk person has high triglycerides or low HDL-C, combiningafibrate or nicotinic acid with an LDL-lowering drug can be considered. ‡‡For moderately high-risk persons, when LDL-C level is 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an 6 LDL-C level 100 mg/dL isatherapeutic option on the basis of available clinical trial results. Step 6 Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

TLC Features

I TLC Diet: — Saturated fat <7% of calories, cholesterol <200 mg/day — Consider increased viscous (soluble) ber (10-25 g/day) and plant stanols/sterols (2g/day) as therapeutic options to enhance LDL lowering I Weight management I Increased physical activity.

I Consider drug simultaneously with TLC for CHD and CHD equivalents I Consider adding drug to TLC after 3 months for other risk categories.

Drugs Affecting Lipoprotein Metabolism

Drug Class Agents and Lipid/Lipoprotein Side Effects Contraindications Daily Doses Effects

HMG CoA reductase Lovastatin (20-80 mg) LDL ↓18-55% Myopathy Absolute: inhibitors (statins) Pravastatin (20-40 mg) HDL ↑5-15% Increased liver • Active or chronic Simvastatin (20-80 mg) TG ↓7-30% enzymes liver disease Fluvastatin (20-80 mg) Relative: Atorvastatin (10-80 mg) • Concomitant use of certain drugs* Rosuvastatin (5-40 mg) Pitavastatin (1-4 mg)

Bile acid sequestrants Cholestyramine (4-16 g) LDL ↓15-30% Gastrointestinal Absolute: Colestipol (5-20 g) HDL ↑3-5% distress • dysbeta- lipoproteinemia Colesevelam (2.6-3.8 g) TG No change Constipation or increase Decreased absorp- • TG >400 mg/dL tion of other drugs Relative: • TG >200 mg/dL

Nicotinic acid Immediate release LDL ↓5-25% Flushing Absolute: (crystalline) nicotinic acid HDL ↑15-35% Hyperglycemia • Chronic liver disease (1.5-3 gm), extended TG ↓20-50% Hyperuricemia • Severe gout release nicotinic acid (or gout) Relative: ® (Niaspan ) (1-2 g), Upper GI distress • Diabetes sustained release Hepatotoxicity • Hyperuricemia nicotinic acid (1-2 g) • Peptic ulcer disease

Fibric acids Gemfibrozil LDL ↓5-20% Dyspepsia Absolute: (600 mg BID) (may be increased in Gallstones • Severe renal disease patients with high TG) Fenofibrate Myopathy • Severe hepatic (48 mg,145 mg,200 mg) HDL ↑10-20% disease Clofibrate TG ↓20-50% (1000 mg BID) Fenofibric Acid (45mg, 135 mg)

Cholesterol adsorption Ezetimibe (10 mg) LDL ↓18% Upper respiratory Statin contraindications inhibitors apoB ↓ 15-16% infections apply when used with a TG ↓ 7-9% Diarrhea statin. Arthralgia

Lipid combination Ezetimibe/simvastatin LDL ↓ 46-58% Headache Active liver disease or (10/10 mg to apoB ↓ 35-47% Increased ALT unexplained persistent 10/80 mg) TG ↓ 26-31% Myalgia elevation of hepatic Upper respiratory transminase levels tract infection Women who are pregnant Diarrhea or who may become pregnant Nursing mothers

* Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors ( brates and niacin should be used with appropriate caution).

52 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 8 Identify metabolic syndrome and treat, if present, after 3 months of TLC. Step 8 Criteria for Clinical Diagnosis of Metabolic Syndrome Measure (any 3 of 5 constitute Categorical Cutpoints diagnosis of metabolic syndrome

Elevated waist circumference*† >102 cm (>40 in) in men Ty ma Co p mpr

>88 cm (>35 in) in women n e 2 ag e >150 mg/dL (1.7 mmol/L) dia e h Elevated triglycerides m en en

or be si t

On drug treatment for elevated triglycerides‡ t of e ve s Reduced HDL-C <40 mg/dL (1.03 mmol/L) in men <50 mg/dL (1.3 mmol/L) in women or On drug treatment for reduced HDL-C‡

Elevated blood pressure >130 mmHg systolic blood pressure or > 85 mmHg diastolic blood pressure or On antihypertensive drug treatment in a patient with a history of hypertension

Elevated fasting glucose >100 mg/dL or On drug treatment for elevated glucose

*To measure waist circumference, locate top of right iliac crest. Place a measuring tape in a horizontal plane around abdomen at level of iliac crest. Before reading tape measure, ensure that tape is snug but does not compress the skin and is parallel to floor. Measurement is made at the end of a normal expiration.

†Some US adults of non-Asian origin (eg, white, black, Hispanic) with marginally increased waist circumference (eg. 94-101 cm [37-39 inches] in men and 80-87 cm [31-34 inches] in women) may have strong genetic contribution to insulin resistance and should benefit from changes in lifestyle habits, similar to men with categorical increases in waist circumference. Lower waist circumference cutpoint (eg, >90 cm [35 inches] in men and >80 cm [31 inches] in women) appears to be appropriate for Asian Americans.

‡Fibrates and nicotinic acid are the most commonly used drugs for elevated TG and reduced HDL-C. Patients taking one of these drugs are presumed to have high TG and low HDL.

Reference: Grundy, et al. (2005). Diagnosis & Mgmt of the Metabolic Syndrome. Table 2. AHA/NHLBI Scientific Statement. Circulation. 112: 2735-2752.

Treatment of the Metabolic Syndrome

I Treat underlying causes (overweight/obesity and physical inactivity): – Intensify weight management – Increase physical activity.

I Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies: – Treat hypertension – Use aspirin for CHD patients to reduce prothrombotic state – Treat elevated triglycerides and/or low HDL (as shown in Step 9).

ATP III Classification of Serum Triglycerides (mg/dL)

<150 Normal 150-199 Borderline high 200-499 High ≥500 Very high

Treatment of elevated triglycerides (≥150 mg/dL)

I Primary aim of therapy is to reach LDL goal I Intensify weight management I Increase physical activity I If triglycerides are >200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total – HDL) 30 mg/dL higher than LDL goal.

Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories

Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL) CHD and CHD Risk Equivalent <100 <130 (10-year risk for CHD >20%) Multiple (2+) Risk Factors and <130 <160 10-year risk <20% 0-1 Risk Factor <160 <190

If triglycerides 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:

• intensify therapy with LDL-lowering drug, or • add nicotinic acid or fibrate to further lower VLDL.

If triglycerides >500 mg/dL, first lower triglycerides to prevent pancreatitis:

• very low-fat diet (<15% of calories from fat) • weight management and physical activity • fibrate or nicotinic acid • when triglycerides <500 mg/dL, turn to LDL-lowering therapy.

Treatment of low HDL cholesterol (<40 mg/dL)

I First reach LDL goal, then: I Intensify weight management and increase physical activity I If triglycerides 200-499 mg/dL, achieve non-HDL goal I If triglycerides <200 mg/dL (isolated low HDL) in CHD or CHD equivalent consider nicotinic acid or fibrate.

54 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Hard Coronary Heart Disease (10-Year Risk)

EstimateMen of 10-Year Risk for Men EstimateWomen of 10-Year Risk for Women (Framingham Point Scores) (Framingham Point Scores)

Age Points Age Points 20-34 -9 20-34 -7 35-39 -4 35-39 -3 40-44 0 40-44 0 45-49 3 45-49 3 50-54 6 50-54 6 55-59 8 55-59 8 60-64 10 60-64 10 Ty ma Co p 65-69 11 65-69 12 mpr n e 2

70-74 12 70-74 14 ag 75-79 13 75-79 16 e dia e h m en en be si t Points Total Points t of e

Total ve Cholesterol Cholesterol s Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 <160 0 0 0 0 0 160-199 4 3 2 1 0 160-199 4 3 2 1 1 200-239 7 5 3 1 0 200-239 8 6 4 2 1 240-279 9 6 4 2 1 240-279 11 8 5 3 2 ≥280 11 8 5 3 1 ≥280 13 10 7 4 2

Points Points

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

Nonsmoker 00 000 Nonsmoker 00 000 Smoker 85 311 Smoker 97 421

HDL (mg/dL) Points HDL (mg/dL) Points ≥60 -1 ≥60 -1 50-59 0 50-59 0 40-49 1 40-49 1 <40 2 <40 2

Systolic BP (mmHg) If Untreated If Treated Systolic BP (mmHg) If Untreated If Treated <120 0 0 <120 0 0 120-129 0 1 120-129 1 3 130-139 1 2 130-139 2 4 140-159 1 2 140-159 3 5 ≥160 2 3 ≥160 4 6

Point Total 10-Year Risk % Point Total 10-Year Risk % <0 < 1 < 9 < 1 0 1 9 1 1 1 10 1 2 1 11 1 3 1 12 1 4 1 13 2 5 2 14 2 6 2 15 3 7 3 16 4 8 4 17 5 9 5 10 6 18 6 11 8 19 8 12 10 20 11 13 12 21 14 14 16 22 17 15 20 23 22 16 25 10-Year risk ______% 24 27 10-Year risk ______% ≥17 ≥ 30 ≥25 ≥ 30

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NIH Publication No. 01-3305 Public Health Service May 2001 National Institutes of Health National Heart, Lung, and Blood Institute

Therapies focused on modification of patient lifestyle (Therapeutic Lifestyle Changes or TLC), including medical nutrition therapy (MNT) and exercise programs, are essential to achieving glycemic, lipid and blood pressure control, moderate weight loss and reduction of cardiovascular risk factors.

Tips for Supporting Lifestyle Change • Encourage lifestyle modifications that reduce total caloric intake, saturated and trans fat consumption and cholesterol and sodium intake such as: o Consume carbohydrates from fruits, vegetables whole grains, legumes and low-fat milk o Monitor carbohydrate intake o Consume a variety of fiber-rich foods like beans, berries and greens o Limit sodium intake • Encourage moderate to vigorous physical activity to improve glucose, lipid and blood pressure values • Refer patients to registered dietician and/or to Medical Nutrition Therapy for additional support • Encourage patients to quit smoking

Tlab e 25 Recommended Lifestyle Modifications Target Therapy Goal Recommendations Overweight and obesity Healthy weight and BMI Advise weight reduction to optimize BMI ≥18.5 and <25

Physical inactivity Regular physical activity 150 minutes of moderate to vigorous exercise per week Resistance training 2-3 times per week that works all the major muscle groups

Diet/nutrition Reduced saturated fat, Reduced saturated fat to <7% of total trans fat and cholesterol calories intake. Minimize trans fats Dietary cholesterol < 200 mg/day

Reduced sodium intake <1.5 grams/day

Consumption of fiber Fiber 14 grams/day Alcohol intake Restriction alcohol Less than/equal to 1 drink per day for consumption women and 2 drinks per day for men Smoking Tobacco cessation Advise patient to quit smoking, offer cessation resources ^ BMI = Body Mass Index

56 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Weight Loss/Maintenance Even a moderate loss of 5-10% of overall body weight in patients with diabetes will result in improvement of blood glucose, blood pressure and lipids profile.

Nearly 80% of patients who lose weight will gradually regain it if they are not supported by a weight maintenance program. The keys to a successful weight maintenance program are patient motivation and team support from health care providers. Effective management of overweight and obesity can be delivered by a variety of healthcare providers including primary care providers, registered dietitians, nutritionists, exercise physiologists, nurses, and psychologists. Ty ma Co p mpr n

Achieving and maintaining an appropriate body weight requires daily effort, good dietary/ e 2 ag e nutritional behaviors and adequate physical activity. Combined management approaches (diet, dia e h m en en

exercise and behavior modification) are likely to produce better results than any single approach. be si t t of e ve Healthcare providers should encourage patients to consult their health plan for weight loss/ s maintenance programs that may be covered by their policy.

Medical Nutrition Therapy (MNT)9,36,40,41 Medical Nutrition Therapy (MNT) services involve a nutritional assessment, specific diet planning, and counseling services to prevent or treat an illness or medical condition. MNT counseling services are typically provided by a registered dietitian (RD) focusing on behavior and lifestyle changes with the goal of addressing nutrition problems and associated medical conditions, such as diabetes. MNT goals for the treatment of diabetes focus on interventions to maintain blood glucose, lipids, and blood pressure within a normal range in order to prevent or slow the rate of development of the chronic complications of the disease. In addition, MNT can be useful in helping patients with diabetes to achieve and maintain a healthy body weight. During each counseling session, the RD works with patients to assess individual needs, determine goals, develop a care plan, and monitor overall progress towards treatment goals.

Coverage for and access to MNT services vary by health insurance program or carrier. Patients should consult with their health insurance evidence of coverage booklet or call their health plan regarding coverage for MNT services. Medicare currently covers MNT services for people with diabetes or renal disease as a means of helping to manage the condition covering. Medicare covers 3 hours of one-on-one counseling the first year, and 2 hours each subsequent year. Beneficiaries may be able to receive more hours of treatment with a physician’s referral if the condition, course of treatment or diagnosis changes. Physicians must prescribe MNT services for Medicare recipients and renew the referral annually as necessary.41

For a list of CPT codes for MNT, please go to chapter 7, page 139.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 57 General Nutritional Recommendations for Diabetes36 • Regular and individualized meal planning advice. • Total carbohydrate (in grams) monitoring to help control glycemia. • Balance calories from foods and beverages with calories used. • Consume varieties of nutrient and vitamin rich foods and beverages. • Limit saturated fat intake to < 7% of total calories. • Limit intake of trans fats. • Limit cholesterol intake to < 200 mg/day. • Limit sodium intake to < 1,500 mg/day (in patients with hypertension) with a diet high in fruits, vegetables, and low-fat dairy products to lower blood pressure. • Daily alcohol intake should be limited to < 1 drink/day for women and < 2 drinks/day for men)

Table 26: Modifiable Nutrients and Fats Tlab e 26 Modifiable Nutrients and Fats

Saturated fat < 7% of total calories Polyunsaturated Up to 10% of total calories fat Monounsaturated Up to 20% of total calories fat Total fat 25-35% of total calories

Cholesterol < 200 mg/day Carbohydrates 50-60% of total calories

Protein Approx. 15% of total calories

Soluble fiber 10-25 g/day Plant 2 g/day stanols/sterols Total calories Balance energy intake with expenditure

Nutritional Recommendations for Weight Loss In Diabetes9 • Moderate decreases in calories (500-1000 kcal/day) can result in progressive weight loss of 1-2 lbs/week. • Low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year) for weight loss. • Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.

Physical Activity and Exercise In Diabetes9 • At least 150 minutes of moderate/intense aerobic activity per week (30 minutes, five days a week) • In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training 3 days/week

58 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

Preventing and 4 Managing Complications of Type 2 Diabetes

• Acute Complications -Hypoglycemia -Diabetic Ketoacidosis (DKA)

• Long Term Complications -Foot Care -Depression and Mental Health -Dental and Oral Care -Eye Health -Renal Health -Nervous System -Tobacco and Smoking

As discussed in the previous chapter, patients with diabetes are at greater risk of common comorbidities such as heart attack, congestive heart failure and chronic kidney disease than patients without diabetes. This chapter discusses both acute and long term complications of uncontrolled blood glucose, blood pressure and lipids.

Acute Complications23,31,42 Poorly controlled diabetes can cause acute complications that are life threatening and should be considered emergencies requiring immediate treatment. Acute complications include:

TableTl 2ab7: eAcute 27 Acute Complications Complications of Diabetes, of Diabetes, Hypertension Hypertension and and Dyslipidemia Dyslipidemia

Type 2 Diabetes Hypertension Dyslipidemia Mellitus Hypoglycemia Myocardial infarction Cerebrovascular Nonketotic Cerebrovascular stroke stroke hyperosmolar state Congestive heart failure Coronary artery (NKHS) or coma, also Nephropathy (kidney disease known as a diabetic failure) Myocardial infarction coma Retinopathy (heart attack) Diabetic ketoacidosis Atherosclerosis (DKA) (damaged or clogged Lactic acidosis arteries)

Hypoglycemia Avoiding hypoglycemia (low glucose levels) is a critical component of diabetes management. In patients with type 2 diabetes, hypoglycemia is often typically associated with the use of insulin and sulfonylureas. The risk of hypoglycemia is greater in older patients, those with longer duration of the disease, those with lesser insulin reserve and patients with strict glucose control.8 The American Diabetes Association recommends that patients with one or more episodes of severe hypoglycemia may benefit from short-term relaxation of glycemic targets. In adults with type 2 diabetes, treatment strategies should avoid medications that can produce severe hypoglycemia.8 The risk of experiencing drug interactions and negative side effects relative to the expected benefits should be discussed with the patient when deciding medication regimens to treat and control diabetes.

Consider using the ADA ‘Rule of 15’ for managing low blood sugar. The Rule of 15 states that if you have a low glucose level, take 15 grams of mostly sugar or carbohydrates. After 15 minutes, test your blood glucose again. If your glucose level is still less than 70, take 15 more grams of carbohydrates. Once your blood glucose level is in a normal range, eat a light snack, if it will be more than one hour before your next meal. For more information go to: http://www.diabetes.org/ livingwith-diabetes/treatment-andcare/blood-glucosecontrol/hypoglycemia-lowblood.html

60 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis (DKA) more commonly occurs in patients with type 1 diabetes but can also occur in patients with type 2 diabetes if blood sugar levels go untreated. DKA can develop very quickly as a result of illness, infection or stress. Patients should be advised to contact their physician immediately if blood sugar values are over 240 mg/dL or ketones are present in the urine. Signs and symptoms of DKA, may include: • Unusual hunger or thirst • Increased urinary frequency • The patient has thrown up or feels sick to their stomach • Stomach pain • Fruity breath smell • Breathing, fast and deep • Unexplained fever

Ty c ma P o r p mp 43,44 even n e 2 D

Long Term Complications agi l icati ti n ia g Over time, failure to properly manage blood glucose, blood pressure and lipid levels can lead to n be

g on

a cardiovascular disease, chronic kidney disease, nervous system damage, periodontal disease, t e n s s d and vision problems, among other comorbidities. Preventing these types of complications involves of

reaching balance and control over blood glucose levels, blood pressure and lipids. This can be achieved through lifestyle modification and medication therapy. Both lifestyle modification and medication therapy are discussed in the previous chapter.

The table below lists common long term complications of diabetes.

Table 28:Tl ab Commone 28 Common Long Term Long Complications Term Complications of Diabetes of Diabetes

Dental and gum disease Nerve damage (neuropathy) Foot problems Persistent skin or gum infections Stomach paralysis Sexual impotence (gastroparesis) Heart disease Vision problems Heart attack Retinopathy Stroke Cataract Damage to blood vessels Glaucoma Kidney disease/failure

Key Messages The following are key messages that all health care providers can promote and discuss during the patient visit. • Promote the ABC’s – A1c, Blood Pressure and Cholesterol o Ask: Ask patients whether they know their ABC goals and how to reach them o Advise: Explain how to prevent complications to your patients; o Assist: Provide patients with educational materials and other self management resources, preferably in their language of preference

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 61 • Promote a healthy lifestyle o Help patients set realistic short and long term goals o Counsel on diet, nutrition and physical activity o Advise patients to aim for a healthy weight o Assess for lifestyle risk factors, such as tobacco use • Explain the risks of diabetes and the benefits of good self management o Provide care and services according to recommended guidelines • Discuss medication adherence o Discuss the benefits of taking medications as directed o Review medications at every visit o Ask patients to bring their medications to each visit o Ask patients if they are having any problems with taking their medications • Assess symptoms and provide the appropriate referrals

Foot Care45,46 Routine Visual Foot Exams During every patient visit Common diabetes-related foot conditions include neuropathy, vasculopathy, dermatological conditions, and musculoskeletal problems. The objectives of the routine foot exam are to identify foot problems, document findings, evaluate need for more comprehensive foot exams, provide follow-up care, and make referrals to specialists. Basic Instructions Physician or other medically trained office staff, every visit: 1. Inspect the foot from toes to heel looking for skin injuries, calluses, blisters, ulcers, fissures, or other unusual conditions. 2. Assess signs of decreased vascular supply which may include thin, fragile, shiny, and hairless skin. 3. Feel the foot for excess warmth and/or dryness. 4. Inspect nails for thickening, ingrowths, proper length and fungal infections. Remove nail polish as necessary. 5. Schedule a comprehensive foot exam and refer for follow-up if patient presents with new foot abnormalities. 6. Document all exam findings in the medical record.

Annual Comprehensive Foot Exam Once annually or as needed Also known as a monofilament foot exam, the objectives of the annual comprehensive foot exam are to determine if the patient is experiencing any foot complications like those listed above, to identify the need for therapeutic foot wear, and to provide assessment for further treatment and referral to specialists as needed. Provide the patient with comprehensive self-management education and assist them in developing a self-management foot care plan to prevent future abnormalities. Basic Instructions Physician: 1. Document the presence of any diabetic complications including eye, kidney, nerve and vascular. 2. Evaluate any history or presence skin injuries, calluses, blisters, ulcers, fissures, or other unusual conditions.

62 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 3. Examine the ankles and feet, including between the toes. 4. Measure and document any calluses, lesions, and ulcers. 5. Document foot deformities and/or atrophy of plantar fat pad. 6. Check pedal pulses. 7. Perform monofilament sensory exam. (use 5.07 monofilament - See LEAP Diabetic Foot Screen resource below) 8. Assess patient’s risk status. 9. Check patient’s footwear for proper fit, excess wear, and foreign objects. 10. Identify and address patient education needs. 11. Complete and discuss self foot care needs, diagnostic studies, and referrals for follow-up care.

Risk Status As mentioned, diabetes significantly increases the risk of developing foot complications like neuropathy, vasculopathy, musculoskeletal symptoms, ulcerations, and other dermatological conditions. Risk factors which raise the potential risk of adverse events include:

• Having diabetes for over ten years Ty c ma P o r p mp even n

• Poor glycemic control e 2 D agi l

• Patients on dialysis icati ti n ia g n

• Family history of cerebrovascular accidents and coronary artery disease be

g on

a • Inherited foot shapes may predispose to deformities that may lead to skin breakdown t e n s s d of

• Smoking

Basic Foot Self-Care and Education While the routine and comprehensive medical foot exams are an important part of the prevention process, it is also important that patients develop a foot care plan which they can implement at home. Discuss with the patient the importance of reporting to their health care team any blood or other discharges on socks or hose, encourage them to regularly replace worn foot wear, check for foreign objects, and to wear materials that promote good airflow and fit properly.

As mentioned, diabetes significantly raises the risk of developing foot ulcers which can lead to amputation. Smoking increases this risk, so discuss quitting with your patients as well. Proper self- care and regular medical examinations of the feet for abnormalities, combined with good glycemic control, reduces these risks. Below are some additional resources to work with the patient in order to insure better diabetic foot health.

Additional Foot Care Resources • ADA- Foot Complications http://www.diabetes.org/type-1-diabetes/foot-complications.jsp • NIDDK – Feet Can Last a lifetime http://www.ndep.nih.gov/diabetes/pubs/Feet_HCGuide.pdf • NIDDK – Prevent Diabetes Problems: Keep your feet and skin healthy http://www.diabetes.niddk.nih.gov/dm/pubs/complications_feet/index.htm • LEAP- Lower Extremities Amputation Prevention http://www.hrsa.gov/leap/ • ONLINE COURSE: Lower Extremity Amputation Prevention and Treatment of the Neuropathic Foot http://www.hrsa.gov/hansensdisease/pdfs/leaptrainingonline.pdf

Foot Care Tips

Take Care of Your Feet for a Lifetime.

1. Take care of your diabetes. 8. Protect you feet from hot and cold. •Work with your health care team to keep your • Wear shoes at the beach or on hot pavem e n t . blood sugar within a good range. • Wear socks at night if your feet get cold.

2. Check your feet every day. • Don ’t test bath water with your feet. • Look at your bare feet every day for cuts, • Don ’t use hot water bottles or heating pads. blisters, red spots, and swelling. •Use a mirror to check the bottoms of your feet 9. Keep the blood flowing to your feet. or ask a family member for help if you have • Put your feet up when sitting. trouble seeing. • Wiggle your toes and move your ankles up and do wn for 5 minutes, 2 or 3 times a day. 3. Wash your feet every day. • Don ’t cross your legs for long periods of time. •Wash your feet in warm, not hot, water every day. • Don ’t smoke. • Dry your feet well. Be sure to dry between 10. Be more active. the toes. • Plan your physical activity program with 4. Keep the skin soft and smooth. your doctor. • Rub a thin coat of skin lotion over the tops and 11. Check with your doctor. bottoms of your feet, but not between your toes. •Have your doctor check your bare feet and find 5. Smooth corns and calluses gently. out whether you are likely to have serious foot • If your feet are at low risk for problems, use a problems. Remember that you may not feel the pumice stone to smooth corns and calluses. pain of an injury. Don ’t use over-the-counter products or sharp • Call your doctor right away if you find a cut, objects on corns or calluses. sore, blister, or bruise on your foot that does not begin to heal after one day. 6. If you can see and reach your toenails, trim • Follow your doctor’s advice about foot care. them each week or when needed. • Trim your toenails straight across and file 12. Get started now. the edges with an emery board or nail file. • Begin taking good care of your feet today.

7. Wear shoes and socks at all times. • Set a time ever y day to check your feet. • Nev er walk baref o o t . • Complete the “To Do” list on the back of this • Wear comfortable shoes that fit well and page and… pr otect your feet. take care of your feet • Feel inside your shoes before putting them on each time to make sure the lining is smooth for a lifetime. and there are no objects inside.

64 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 DIABETES FOOT EXAM

Patient Name: ______Last First MI DOB: ______Medical Record #: ______DETAILED FOOT EXAM: Initially and then yearly Date: Indicate presence (+) or absence (-) in the space below: Dorsalis pedis Posterior Ulcer (note Bony deformity/ Loss of hair/ pulse tibial pulse size if present) Callus Atropic skin Right Left

Indicate presence (+) or absence (-) of sensation Notes: in 5 areas using 10gm monofilament ______

______Ty c ma P o r p mp even n

______e 2 D agi

______l icati ti n ia g ______n be

g on

______a t e n s s

______d of Education/education materials given

Provider Signature: ______

VISUAL INSPECTION ONLY: at every diabetes care visit Date:______

Normal Abnormal; specify______Education/education materials given No referral Referral to______

Provider Signature: Date:______

Normal Abnormal; specify______Education/education materials given No referral Referral to______

Provider Signature: Date:______

Normal Abnormal; specify______Education/education materials given No referral Referral to______

Provider Signature:

Page 1 of 1. This product is part of the Basic Guidelines for Diabetes Care Packet and may be reproduced with the citation: “Developed by the Diabetes Coalition of California and the California Diabetes Program, revised August 2009.” For further information: www.diabetescoalitionofcalifornia.org / www.caldiabetes.org / (916) 552-9888

Source: Feet Can Last a Lifetime: A health care provider’s guide to preventing diabetes foot problems. National Diabetes Education Program (NDEP). November 2000.

The overwhelming impact of a new diagnosis, the daily stress of managing diabetes and its complications can have a strong impact on your patient’s mental health. Anyone is susceptible to anxiety and depression, but studies have shown that persons with diabetes are 52% more likely to become depressed than persons without diabetes. Conversely, persons who are depressed are more likely to develop diabetes.47,48

Both diabetes and depression put the patient at higher risk of dying from coronary heart disease, so it is important to screen and treat your patients with diabetes regularly for signs of depression in order to reduce this risk.49

Screening for Symptoms It is important to remember that there are numerous possible symptoms of depression that will be different for each individual case. The following symptoms tend to be consistent with depression:

Tlab e 29 Symptoms of Depression

• Persistent feeling of sadness or hollowness • Overwhelming feelings of hopelessness and negativity • Feeling helpless and powerless to change situation • Loss of interest in activities or loss of pleasure • Loss of energy and increased fatigue • Change in sleep patterns (Insomnia, oversleeping, awakening early in the morning) • Trouble concentrating, memory problems and indecisiveness • Dwelling on death or suicide • Restlessness, overriding anxiety • Weight change and decreased or increased appetite • Persistent aches and pains, headaches, cramps or digestive problems that do not ease even with treatment

If your patient reports experiencing any of these symptoms consistently, consider further screening. The symptoms of poorly controlled blood sugar levels can also mimic those of depression. Better self-management skills and blood glucose stability can help alleviate these symptoms.

The Patient Health Questionnaire (PHQ-9) offers health care providers a quick and self administered screening and diagnostic tool for evaluating major depressive disorder.

66 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Antipsychotic Therapy & Monitoring of Risks50 Providers should be aware that there are metabolic side effects of some antipsychotic drugs. This includes possible increases in lipids, decrease in protective HDL and weight gain. There also seems to be an association between some antipsychotics and diabetes risk. While the choice of antipsychotic drugs depends on many patient specific factors, the American Diabetes Association and the American Psychiatric Association recommend that health care providers consider the individual patient risk factors for diabetes and cardiovascular disease when treating and prescribing. Regular monitoring for risks should also occur.

TlabTablee 30 30 Monitoring: Monitoring Protocol Protocol for Patients for Patients on Atypical on Atypical Antipsychotics Antipsychotics

Baseline Month Month Month Quarterly Annually Every 5 1 2 3 Years

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circumference t e n s s d Blood pressure X X X of Fasting plasma X X X glucose Fasting lipid X X X profile

Additional Depression and Mental Health Resources

• ADA Depression http://www.diabetes.org/living-with-diabetes/complications/mental-health/depression.html

• Behavioral Diabetes Institute www.behavioraldiabetesinstitute.org

• Patient Health Questionnaire (PHQ) Screeners www.phqscreeners.com/overview.aspx

This web site offers health care providers concise, self-administered screening and diagnostic tools to support the evaluation and treatment of depression and mental health disorders.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 67

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

NAME: ______DATE:______

Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) Not at all Several days Morethe than days half Nearly every day

1. Little interest or pleasure in doing things 0123

2. Feeling down, depressed, or hopeless 0123

3. Trouble falling or staying asleep, 0123 or sleeping too much

4. Feeling tired or having little energy 0123

5. Poor appetite or overeating 0123

6. Feeling bad about yourself—or that you are a failure or have let yourself 0123 or your family down

7. Trouble concentrating on things, such as reading the 0123 newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety 0 1 23 or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead, 0 123 or of hurting yourself in some way

add columns: + +

(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card.)

10. If you checked off any problems, how Not difficult at all ______difficult have these problems made it for you to do your work, take care of things at Somewhat difficult ______home, or get along with other people? Very difficult ______

Extremely difficult ______

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at [email protected]. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com. Copyright ©1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.

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68 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Dental and Oral Care51 Though everyone is susceptible to gum and dental disease, people with diabetes are at a greater risk of developing severe periodontal (gum) disease. The excess of glucose in the blood can feed infections that, if left untreated, can lead to tooth loss. Conversely, the presence of periodontal disease can make management of blood glucose levels more difficult.

During the Visit • Explain the link between poor blood glucose control and gum disease to your patients • Stress the importance of good oral hygiene and regular dental exams • Refer patients with diabetes to see the dentist twice yearly for checkups and cleanings

Table 31: Dental Care Tips

Share these Dental Care Tips with your Patients

• Floss daily to prevent plaque buildup. Ty c ma P o r p mp even n • Use a soft toothbrush to brush teeth after meals and snacks. e 2 D agi l icati

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a t e n s s d Do not delay to tell your doctor if something appears wrong or unusual with your teeth or of

gums.

Signs & Symptoms Advise patients with diabetes to report any signs of: • Redness, soreness and bleeding in the gums • Gums pulling away from the teeth • Loose or sensitive teeth • Dentures that fit poorly • Bad breath Refer patients to see a dentist if they report any of these signs or symptoms. Note that many people with diabetes can be asymptomatic for periodontal disease; highlighting the importance of referring your patients to a dentist for regular check-ups and cleanings.

Additional Oral Care Resources • ADA - Oral Health and Hygiene http://www.diabetes.org/living-with-diabetes/treatment-and-care/oral-health-and-hygiene/ • NIDDK - Prevent diabetes Problems: Keep teeth and gums healthy http://www.diabetes.niddk.nih.gov/dm/pubs/complications_teeth/index.htm • NDEP - Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry, and Dental Professionals http://www.ndep.nih.gov/media/PPODprimer_color.pdf

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 69 E ye Health52 Over time, high blood glucose levels and elevated blood pressure can cause damage to the retina and small blood vessels in the eyes. This damage can lead to more severe problems including diabetic retinopathy, cataracts and glaucoma, and may eventually lead to loss of vision without treatment. It is important to refer patients with type 2 diabetes to an ophthalmologist annually for a dilated eye exam.

Preventing Eye Problems • Discuss the link between hypertension and blood glucose control on eye health with your patients • Schedule or refer your patients for a dilated eye exam once a year, even when no symptoms are present. o Dilated eye exams – Used to identify diabetic retinopathy which occurs when small blood vessels in the eye are damaged by elevated blood glucose levels. Retinopathy is the most common eye disease associated with type 2 diabetes.33 o Recommended annually in all patients. o Note: A refraction exam for new glasses is generally not sufficient for the purposes of a diabetic retinal eye exam.

Signs & Symptoms Though there may be no signs of retinal damage, encourage your patients to report any of the following: • Blurry or double vision • Rings, flashing lights or blank spots • Dark or floating spots • Pain or pressure in one or both eyes • Trouble seeing things out of the corners of the eyes

Treatment of Eye Problems • Cataracts may be able to be treated through surgery • Glaucoma may be treated to lessen the pressure within the eye with special eye drops and possibly laser surgery

Additional Eye Care Resources • ADA –Eye Complications http://www.diabetes.org/living-with-diabetes/complications/eye-complications/

• NIDDK – Prevent Diabetes Problems: Keep your eyes healthy http://www.diabetes.niddk.nih.gov/dm/pubs/complications_eyes/index.htm

70 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Renal Health30,53 Even with proper control, diabetes can lead to chronic kidney disease (CKD) and kidney failure. This type of kidney disease takes many years to develop. In some people, the filtering functions of the kidneys are higher than normal in the initial years of having diabetes.

Over time, individuals with developing kidney disease will have small amounts of blood protein albumin leak into their urine resulting in microalbuminuria. If left untreated, the presence of protein in the urine will gradually give way to macroalbuminuria or proteinuria causing a decrease in kidney filtration and coinciding with increase in blood pressure. For more severe cases of kidney failure, hemodialysis or peritoneal dialysis may be required to filter waste products and extra fluid from the blood. In some cases, a kidney transplant may be necessary.

Signs & Symptoms Kidney failure can occur with little to no signs or symptoms. Only regular urine tests for creatinine

and microalbumin measure how well the kidneys are functioning. Feeling sick to the stomach, Ty c ma P o r p mp even feeling tired all the time, swelling of the hands and feet, and frequent urinary tract infections are all n e 2 D agi

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a • Microalbumin/creatinine ratio – Checks for the presence of protein (albumin) in the urine. The t e n s s d normal microalbumin/creatinine ratio is less than 30. A microalbumin/creatinine ratio of 30-299 of

is called microalbuminuria. A ratio ≥ 300 is considered macroalbuminuria (clinical albuminuria). In type 2 diabetes, patients with an abnormal microalbumin/creatinine ratio (≥ 30) are at increased risk of developing cardiovascular diseases (CVD) and nephropathy. • Serum creatinine – Typically ordered with a BUN (blood urea nitrogen) test as part of a basic or comprehensive metabolic panel to assess kidney function. Such measurements are useful in calculating the estimated glomerular filtration rate (eGFR), used to screen for kidney damage and abnormal function.

Preventing and Treating Kidney Problems Encourage your patients to prevent diabetes-related kidney problems by doing the following:

• Keep blood glucose as close to normal as possible. • Maintain a blood pressure below 130/80 to help prevent damage to the eyes, heart and blood vessels. • Follow a healthy eating plan. • Be active a total of 30 minutes each day. • Complete annual urine and blood testing. • Complete an annual microalbumin/creatinine ratio • Get prompt treatment for bladder or kidney infections.

Some patients may require the use of medication to help slow kidney damage. Commonly prescribed medications include: • ACE (angiotensin converting enzyme) inhibitor • ARB (angiotensin receptor blocker)

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 71 Additional Renal Health Resources • ADA – Kidney Disease (Nephropathy) http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-nephropathy.html • NIDDK – “Prevent Diabetes Problems: Keep Your Kidneys Healthy” and “Kidney Failure: Choosing a Treatment That’s Right for You” http://www.kidney.niddk.nih.gov/kudiseases/ez.asp • NKDEP- National Kidney Disease Education Program Resources http://www.nkdep.nih.gov/resources/index.htm

Nervous System54 Over time, people with diabetes can develop damage to the nervous system. Poorly controlled blood glucose in addition to a variety of metabolic, neurovascular and other factors can damage the blood vessels that carry oxygen throughout the system. Damage can occur among: • Peripheral nerves (arms, hands, legs and feet) • Autonomic nerves (heart and blood vessels, digestive system, sweat glands, eyes, lungs, urinary tract and sex organs) • Cranial nerves (head)

Signs & Symptoms Some people with nerve damage will experience no symptoms. For others, symptoms may vary dependent on the affected nerves. Numbness or tingling in the feet, hands, legs or arms are a common symptom. • See our patient education handout Diabetes and Nerve Damage to review a full list of symptoms and encourage your patients to protect their nerves from more damage.

Potential problems There are numerous problems that can develop as a result of diabetes-related nerve damage, including: • Bell’s palsy (facial) • Decreased extremity sensations • Decreased hypoglycemia symptom sensitivity • Decreased digestive efficiency • Erectile dysfunction or impotence • Vaginal dysfunction • Heart irregularity • Decreased bladder control • Decreased blood pressure regulation • Vision problems • Gastroparesis or“stomach paralysis” Further nerve damage can be prevented by: • Talking to your patients about the importance of good blood glucose control • Encouraging proper foot care • Considering the use of medications to help relieve the pain of neuropathies

72 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Additional Nervous System Resources • CMA Foundation Diabetes and Nerve Damage http://www.thecmafoundation.org/projects/APED/NewPatientResouces.aspx • ADA –Neuropathy (Nerve Damage) http://www.diabetes.org/living-with-diabetes/complications/neuropathy

• NIDDK-Diabetic Neuropathies: The Nerve Damage of Diabetes http://www.diabetes.niddk.nih.gov/dm/pubs/neuropathies/index.htm • NIDDK- Prevent Diabetes Problems: Keep your nervous system healthy http://www.diabetes.niddk.nih.gov/dm/pubs/complications_nerves/index.htm

Tobacco and Smoking

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Tobacco as a Major Risk Factor for Diabetes Complications • Increases insulin resistance and chronic inflammation, which can accelerate macrovascular and microvascular complications, including nephropathy, neuropathy and CVD. • Affects the way the body is able to respond to insulin and affects the ability to control diabetes.55 • Increases the risk of developing cardiovascular disease.

Tobacco Cessation Interventions57 It is important to provide information on smoking and tobacco cessation and clear information on the risks associated with smoking to patients with diabetes.

All patients who smoke need to be advised to quit.

Effective treatments exist that can significantly increase rates of successful cessation: • Identify and offer treatment to every tobacco user who comes in for an appointment • Combine counseling and medication o There are now seven effective medications approved by the FDA for treating tobacco dependence. o This is the most effective clinical treatment of tobacco dependence and should be offered to individuals making a quit attempt. • Refer to quitline, or telephone-based counseling o This is effective with diverse populations and has broad reach.

Ask, Advise, Refer58,59,60 Use the Ask, Advise, Refer (AAR) intervention with patients with diabetes who smoke and refer them for cessation counseling at the California Smokers’ Helpline (1-800-NO-BUTTS) or the national 1-800-QUIT-NOW if outside California.

Ask every patient at every visit about tobacco use, frequency of use and type of tobacco used. Document on the patient chart.

Advise patients to quit in a clear and personalized manner. Provide the patient information on why it is important for them to quit. Emphasize the impact tobacco use has on people with diabetes, link facts with the advice. If the patient has previously attempted quitting, encourage them and tell them that patients average 3-8 attempts before permanent quitting is achieved.

Refer the patient to the California Smokers’ Helpline (1-800-NO-BUTTS) or the National 1- 800-QUIT-NOW if outside California, for cessation counseling or to a local cessation class (after assessing the patient’s readiness to attempt quitting). Provide them with information on quitting. Document in the patient chart and schedule a follow-up visit with the patient to discuss their progress. If the patient is not ready to attempt quitting, provide them with the resources and reassess at the next visit.

Materials including the reference guide, patient resources/fact sheets, California Smoker’s Helpline info, and links to other resources are available for download on Diabetes Information Resource Center (developed by the California Diabetes Program) at http://www.caldiabetes.org/content_display.cf m?contentID=55&CategoriesID=75

Additional Smoking and Tobacco Resources • American Lung Association www.lungusa.org • California Smokers Helpline – 1-800-NO-BUTTS www.californiasmokershelpline.org/ • Treating Tobacco Use and Dependence: A Public Health Service Clinical Practice Guideline http://www.ahrq.gov/path/tobacco.htm • Smoking Cessation Leadership Center http://smokingcessationleadership.ucsf.edu/ • How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking- Attributable Disease. A Report of the Surgeon General. December 2010 http://www.surgeongeneral.gov/library/tobaccosmoke/index.html • UPMC – Smoking and Diabetes http://www.upmc.com/HealthAtoZ/patienteducation/D/Pages/smokinganddiabetes.aspx • 1-800 Quit Now http://1800quitnow.cancer.gov/

74 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

Improving Type 2 5 Diabetes Care and Self Management • Patients as Decision-Makers • Supporting Lifestyle Change - Patient and Provider Communication - Readiness for Change - Tips for Supporting Patient Lifestyle Modifications • Brief Negotiations - Assessing Readiness to Change - Diabetes - General - Weight - General - Sample Dialogues Using Brief Negotiations o Insulin Introduction Sample Dialogue o Hypertension Self-Management Sample Dialogue - Brief Negotiations Reference Card • Improving Medication Adherence - Factors that Influence Adherence - Tips to Improve Adherence • Systems and Process Improvement - Office Systems - Chart Prompts - Exam Rooms/Waiting Area - Building the Diabetes Care Team - Patient Activation/Support

Patient follow-through with recommended lifestyle changes and medication use is critical to achieving glycemic, blood pressure and lipid control and long term success in reducing the impact of diabetes and cardiovascular disease.

Patients as Decision-Makers “No medication works How often have we said ‘My patients just won’t do what I tell them?’ The inside a bottle. Our truth is, our patients are the only decision makers in the management of patients reach for their their diabetes. They make daily decisions about diet, exercise, medication pill bottles, unscrew adherence, routine tests, and results tracking - making them the most their caps and reap important decision makers in successful disease management and risk the benefits of our reduction. medications almost It is common for patients with diabetes to struggle with the lifestyle purely because of the changes and medication therapies prescribed by their clinicians. power of their bond Inadequate blood glucose monitoring or missed appointments are also with us. ” common. The challenge we face as healthcare providers is how to partner with our patients and help them most effectively manage their C. Everett Koop, MD diabetes by setting goals that are achievable. Patients sometimes fail to Former Surgeon General of understand that good blood sugar, lipid and blood pressure control are the United States key factors in reducing diabetes complications.

Components of Self Management: Lifestyle Change & Medication Adherence

Lifestyle Change medication adherence

In most cases, treatment of diabetes and cardiovascular disease continues for years. Efforts to effectively manage diabetes will need to cover the patient’s lifespan in order for the benefits of adequate lifestyle modification and medication adherence to be achieved. Lack of follow-through results in most patients missing the benefits of recommended lifestyle changes and prescribed medication.

Supporting Lifestyle Change The first step to increasing greater self-management and adoption of lifestyle changes is to involve patients in their care. Key steps to include are:

• Develop the patient-provider relationship • Assess the patient’s readiness to initiate behavior changes to improve their diabetes. • Provide specific lifestyle modification and self-management instructions.

Patient and Provider Communication1,44,61,62,63,64

76 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Talking about diabetes related complications and co-morbid conditions such as cardiovascular disease require both sensitivity and honesty. The newly diagnosed patient, or those experiencing changes in their care program, will likely have many questions about how the disease and their treatment will affect them and their current lifestyle, whether they ask questions or not. The patient’s motivation and capacity to improve depends on the degree of acceptance of their diagnosis and the severity of their condition, and the relationship between the coaching health care professional and patient.

When a patient is diagnosed with a chronic condition, the magnitude of change may be overwhelming. By anticipating and speaking about some of the concerns and questions which are common for newly diagnosed patients, you can alleviate some of their anxiety and fear.

Tlab e 33 Tips Toward a Better Provider-Patient Relationship ma a I D

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Getting most people to change their habits is no small task. Most individuals must be ready and motivated to Taking Control make change if long term success is to be achieved and (Positive Messaging)

sustained. Discussing changes when a patient is not ready often leads to resistance, denial of problems and 

frustration that may hamper future efforts. Assessing You should be able to live a normal life by taking readiness to change should include discussing a good care of yourself.

patient’s personal details, including: 

• Family Uncontrolled diabetes is a major cause of heart • Attitudes toward diet and exercise disease and stroke, but there are a variety of • Lifestyle and behaviors resources and tools to help track your progress on a daily basis. • Cultural beliefs and values  • Language needs and barriers • Religious beliefs Including exercise on most days of the week • Access to diabetes-related resources helps manage blood sugar and may reduce blood pressure levels. • Any disabilities that may create a barrier  • Time constraints to make sustainable change Making healthy food choices and portion control make a big difference in blood sugar levels There are three elements of decision making a patient must navigate before effectively taking charge of their 

diabetes. They must:65 Your body is not able to use insulin properly; insulin will help you manage your diabetes better 1. Feel something is wrong with them and accept  their diagnosis. 2. Feel motivated to help with what is wrong and Many medication options are available and these prevent future problems. may be used alone or in combination to help you keep healthy blood sugar levels. 3. Believe the pros outweigh the cons in making the changes needed to effectively manage their diabetes and improve their health. The following questions will help a patient determine their readiness for change and make long term changes. Tlab e 35 Readiness to Change – Patient Self-Assessment

• Am I ready to make a change? -People who are not ready to make changes have little motivation. These individuals should be educated about the potential benefits. • How would changing lifestyle positively affect my health and improve my diabetes? • What are some personal barriers to change that could prevent success? • Do I believe and understand why changes are needed? -Belief and understanding of inaction are part of creating motivation. • What is and should be the goal? -Encourage patients to start with simple changes and pick goals that are realistic. • What is one simple and easy change I can do to reach my goal by the next office visit?

78 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tips for Supporting Patient Lifestyle Modifications

• Losing weight - Even a moderate weight loss of 5-10% has a big impact. • Making healthy food choices through meal planning that includes a variety of healthy foods, limiting sugar, salt, fat and cholesterol intake. • Physical activity daily -Taking simple and small steps to reach goals, stay in control, and effectively self manage diabetes at home through goal setting, daily logs/tracking and self evaluation. • Smoking and tobacco use – Patients with diabetes should avoid using tobacco products. All patients who smoke need to be advised to quit and referred to cessation services like a quitline. For more information, go to http://1800quitnow.cancer.gov.

• Have patients keep daily logs and worksheets to promote reaching goals (see chapter 6, page 95). • Talk with the patient about the importance of support from family and friends to help them in their efforts to change behavior and improve their diabetes. • Recommend more frequent office visits for patients unable to reach their goals. • Refer patients to a dietician or certified diabetes educator, where appropriate, for additional support. • Connect patients to web and community resources (e.g. local park and recreation facilities, farmers markets, self management support groups, services at local hospitals or medical centers and other resources for healthy living. ma a D I mpr n ia d n The CMA Foundation also maintains an online Community Resource Directory at www. be

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Communicating with patients about their diabetes and its cardiovascular complications can be viewed as a daunting, time consuming effort. It is through this discussion that health care providers will be able to determine their patients’ readiness to initiate behavior changes to take greater control of their diabetes.

What follows is a provider-to-patient communication technique called Brief Negotiations. Brief Negotiations was developed and tested by Kaiser Permanente. It provides a guided discussion with the patient identifying small steps to initiate change in their health behaviors, and to assess their readiness to begin this change.

There are 5 main components of the Brief Negotiations technique: • Open the encounter by asking open-ended questions; listen and summarize what the patient is saying • Negotiate the agenda; identify the target behavior for improvement • Assess readiness to change; explore ambivalence and barriers • Tailor the intervention to patient needs, history, risk factors • Close the encounter by summarizing the negotiated plan; confirm next steps

On the next several pages you will review three Brief Negotiation overviews, focusing on:

Diabetes in general

Use of insulin

Weight management

Each overview will walk you through how to discuss these issues with your patients and assess their readiness to begin behavior change.

Next are two provider-to-patient sample dialogues which employ the Brief Negotiations methods. One focuses on insulin use, the other on management of hypertension.

If you would like to learn more about Brief Negotiations, you can visit: www.kphealtheducation.org. Click on ‘Brief Negotiation Roadmap’ to sign on to the interactive online program. At this web link, you will find the Brief Negotiations Roadmap, a gateway to an interactive site that allows health care providers the opportunity for additional training and practice with Brief Negotiations.

80 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes – General66

Determining your patients’ readiness for change is essential for success. Discussing changes when a patient is not ready often creates resistance, denial of problems, and frustration which may hamper future efforts. The following tool provides a basis for starting discussions with patients. Using questionnaires may also provide valuable insight while saving valuable office visit time.

Brief Negotiation Skills • Ask open ended questions • Listen • Summarize the patient’s response • Health care provider style: empathetic, accepting and collaborative

Open the Encounter Ask permission • “Would you be willing to spend a few minutes discussing your diabetes? / Are you interested in discussing ways to stay healthy, energized and in control of your diabetes?”

Ask an open-ended question – listen – summarize • “What do you think? / How do you feel about your diabetes? / What have you be doing to ma a D I

manage your blood sugars these days? mpr n ia d n be

ag s ov t elf e Discuss A1c and blood glucose values e i s m n

g car • Provide patients results: “Your current blood glucose level is [state result]. Your A1c results en Ty t

are [state result].The goal for your fasting blood sugar and A1c [state patient’s goal ranges]. e p • Ask for the patient’s interpretation: “What do you make of this?” e 2 • Add your own interpretation or advice as needed AFTER eliciting the patient’s response. “People who manage their diabetes and maintain regular control of their blood sugars are at far less risk for developing heart disease and other health complications related to diabetes.”

Negotiate the Agenda Here are some examples of ways to improve your diabetes self-management, including: • Testing and recording your blood glucose levels at regular intervals. • Taking your medications and/or insulin properly as prescribed. • Participate in at least 1 hour of physical activity every day. - Emphasize the impact exercise has on heart health, which is particularly important due to increased risk as a person with diabetes. • Is there any health topic you would like to discuss further today?

Identify target behavior: Which behavior are you most interested in discussing today? Or is there something else you are thinking of that I haven’t mentioned?

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 81 Assess Readiness • “On a scale from 0 to 10, how ready are you to consider lifestyle changes?” • Straight question: “Why a 5?” or “Tell me what a 5 means to you.” • Backward question: “Why a 5 and not a 3?” • Forward question: “What would it take to feel a bit more ready and move up from a 5 to a 7?”

E xplore Ambivalence Step 1: Ask a pair of questions to help the patient explore the pros and cons of the issue. • “What are some things you like about ______?” AND “What are some things you don’t like about______?” OR • “What are the advantages of keeping things the same?” AND “What are the advantages of making a change?” Step 2: Summarize ambivalence. • “Let me see if I understand what you’ve told me so far….” (begin with reasons for maintaining the status quo, end with reasons for making a change) • Ask: “Did I get it all?”

Tlab e 36 Tailor the Intervention

Unsure 4 – 6 • Where does that leave you now? • Evaluate ambivalence • What do you see as your next steps? • Elicit change talk • What are you thinking / feeling at this point? • Build readiness • Where does ______fit into your future? • How does having diabetes affect you?

Ready 7 – 10 • Why is this important to you now? • Strengthen commitment • What are your ideas for making this work? • Elicit change talk • What is hard about managing your diabetes / weight? • Facilitate action planning • What might get in the way? • How might you work around the barriers? • How might you reward yourself along the way?

82 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Cognitive Behavior Skills – For Patients Ready to Make Changes • Develop awareness of eating habits, activity and lifestyle behaviors. • Identify problem behaviors. • Problem solving and modify behaviors. • Set weekly blood sugar, weight, dietary and physical activity goals. • Use a goal achievement reward system. • Track your blood sugar levels, diet, weight loss and physical activities using a journal or worksheet. • Routinely check weight.

Close the Encounter • Summarize: “Our time is almost up. Let’s take a look at what you’ve worked through today…” • Show appreciation / acknowledge willingness to discuss change: “Thank you for being willing to discuss your diabetes self-management.” • Offer advice; emphasize choice, and express confidence: “I strongly encourage you to be more physically active. The choice to increase your activity, of course, is entirely yours. I am confident that if you will decide to be more active you can be successful.” • Confirm next steps and arrange for follow up: “Are you able to come back in 1 month so we can continue to work together?”

Adapted from the Permanente Medical Group, Inc. Northern California Regional Health Education www.kphealtheducation.org. Do not reproduce without permission. ma a D I mpr n ia d n be

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Brief Negotiation Skills • Ask open ended questions. • Listen. • Summarize the patient’s response. • Health care provider style: empathetic, accepting and collaborative.

Open the Encounter Ask permission. • “Would you be willing to spend a few minutes exploring staying healthy and managing weight? / Are you interested in discussing options to support a healthy weight?” Ask an open-ended question – listen – summarize. • “There are all sorts of behaviors that can help us maintain a healthy weight, what have you done in the past to manage your weight? How are you feeling about possible changes, if any, to help manage your weight?”

Negotiate the Agenda Here are some examples of ways to promote a healthy weight: • Eating a healthy diet. • Get moving. Physically active for 30 or more minutes most days of the week. • Managing stress. • Joining a weight management program/class. • Or, “is there any health topic you would like to discuss further today?” Identify target behavior: Which behavior are you most interested in discussing today? Or is there something else you are thinking of that I haven’t mentioned?

Assess Readiness • “On a scale from 0 to 10, how ready are you to consider [insert patient’s choosen behavior]?” • Straight question: “Tell me about a 5?” • Backward question: “Why a 5 and not a 3?” • Forward question: “What would it take to move you up a bit from a 5 to a 7?”

E xplore Ambivalence Step 1: Ask a pair of questions to help the patient explore the pros and cons of the issue. • “What are the things you like about ______?” AND “What are the things you don’t like about______?” OR • “What are the advantages of keeping things the same, meaning not doing [insert behavior]?”

AND “What are the advantages of making a change?” Step 2: Summarize ambivalence.

84 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 • “Let me see if I understand what you’ve told me so far….” (begin with reasons for maintaining • the status quo, end with reasons for making a change) • Ask: “Did I get it all? / Did I get it right?”

Table 37: Tailor the Intervention

Stage of Readiness Key Questions Not Ready 0 - 3 • Would you be interested in knowing more about • Raise awareness managing your diabetes and heart health? • Elicit change talk • How can I help? • Advise and encourage • What might need to be different for you to consider a change in the future? Unsure 4 – 6 • Where does that leave you now? • Evaluate ambivalence • What do you see as your next steps? • Elicit change talk • What are you thinking / feeling at this point? • Build readiness • Where does ______fit into your future? • How does having diabetes affect you? Ready 7 – 10 • Why is this important to you now? • Strengthen commitment • What are your ideas for making this work? • Elicit change talk • What is hard about managing your diabetes / weight? • Facilitate action planning • What might get in the way? ma a D I

• How might you work around the barriers? mpr n ia d n • How might you reward yourself along the way? be

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g car en Ty t e Cognitive Behavior Skills – For Patients Ready to Make Changes p e 2 • Develop awareness of eating habits, activity and lifestyle behaviors. • Identify problem behaviors. • Problem solving and modify behaviors. • Invite patient to set realistic weekly diet or physical activity goals. • Use a goal achievement reward system. • Use a journal to track dietary changes and physical activities. • Monitor successes (example, check weight if patient would like to).

Close the Encounter • Summarize: “Our time is almost up. Let’s take a look at what you’ve worked through today…” • Show appreciation / acknowledge willingness to discuss change: “Thank you for being willing to discuss this sensitive topic so candidly.” • Offer advice; emphasize choice, and express confidence: “I strongly encourage you to be more [insert target behavior]. The choice to do this, of course, is entirely yours. I am confident that if you decide to [insert target behavior] you can find a way to make it happen.” • Confirm next steps and arrange for follow up: “Would you be willing to come back in 1 month so we can continue to work together?”

Adapted from the Permanente Medical Group, Inc. Northern California Regional Health Education www.kphealtheducation.org. Do not reproduce without permission.

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This scenario is with a male patient, we’ll call him Mr. Salazar. In this discussion, the physician will be discussing with him efforts at lifestyle change as the first step to help control his hypertension.

MD: Mr. Salazar, just to get started, tell me what you’ve been doing to manage your hypertension? Mr. Salazar: Not much. I take my medications but I know I need to lose some weight.

MD: Well, good work taking your medications. That is a definite positive step. You want to lose some weight; that is helpful to reduce blood pressure. How do you think you could do that? Mr. Salazar: Well, I could eat better. MD: And what are your ideas to begin eating better? Mr. Salazar: Well, I could stop eating candy bars and drinking soda pop. MD: That’s a good idea. How often do you eat candy bars and drink soda pop? Mr. Salazar: Well, I drink three cans of Coke a day and eat two candy bars a day.

MD: What changes would you want to make in how often you drink pop and eat those candy bars? Mr. Salazar: Well, maybe I need to cut back. I can’t live without them totally! Maybe I will just drink one can of Coke and 1 candy bar each day. It’s going to be tough but I really need to do this to get my weight down. I’ll talk with my wife so she buys less of these things. MD: Great, Mr. Salazar. I am glad you are planning to cut down on your candy and soda pop intake. This is a great start to eating more healthfully. When would you like to start cutting down on your candy and pop intake? Mr. Salazar: Well, I have three candy bars left at home and since today is Friday, I will start on Monday. MD: To get a sense of how ready you are to tackle this change to promote your goal of weight loss, how ready are you to cut down on your soda pop and candy bars? On a scale of zero to 10? Zero being not ready at all and 10 being totally ready? Mr. Salazar: Well, probably a 7. MD: Great. You will ask your wife not to buy these items and it sounds like you are reasonably sure that you can accomplish this goal. Is that correct?

Mr. Salazar: Yes. MD: I would like to contact you in 2 weeks and see how you are doing with this plan. Can I call you at the number on your file or would you like to call me? Mr. Salazar: Well, my wife has to come back in here in 2 weeks, so can I just see you then? MD: That would be great. I will set some time aside with the front desk to visit with you about your plan at that time.

Summarizing the Dialogue for Charting:

Example: Patient states he wishes to lose weight to help reduce BP. He will accomplish by decreasing intake of sweets (pop, candy). Pt. has readiness rating of 7.

Barriers: Wife purchasing candy and pop. He will ask her not to purchase these items. Will f/u with patient in office in 2 weeks to modify goals as needed per his request.

88 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Brief Negotiations Reference Card66 For quick communication tips to assist in discussing weight, physical activity and proper nutrition with your patients, carry this Brief Negotiations reference card during exams to make the most of the discussion. Tlab e 38 Brief Negotiations Reference Card

Reference Card: Brief Focused Advice

Step #1: Engage the Patient/Parent • Can we take a few minutes together to discuss your health and diabetes? • What do you feel about your health and diabetes? Step #2: Assess Readiness • on a scale of 0-10, how ready are you to consider a change ___? • Why a ___? Why ___ and not a ___? • What would it take to move you from a ___ to a ___? • What might your next steps be? Step #3: Share Information (Optional) • Your current blood glucose and hemoglobin A1c values ma a I D mpr n put you at risk for developing heart disease ia d n be

and other health risks. What do you make of this? ag s ov t elf e • Some ideas for staying healthy and managing your e i s m n

g car diabetes at home include … (use examples) en Ty

• What are your ideas for working toward healthier t e p blood sugar levels/weight? e 2 Step #4: Make a Key Advice Statement I strongly encourage you to… • Get up and exercise, 30-60 minutes a day. • test and record your blood sugar levels regularly. • track your blood sugar levels, diet, and physical activity using a journal or worksheet. Step #5: Arrange For Follow-up • Would you be interested in more information on ways to effectively manage your diabetes at home? • let’s set up an appointment in ___ weeks to discuss this further.

Source: Regional Health Education. Kaiser Permanente, 2008

We wish to thank the Northern California Kaiser Permanente Medical Group, Inc. and Mindy Boccio, MPH, for their assistance in developing the resources on Brief Negotiations and Assessing Readiness to Change found in the Resource Guide. We would also like to acknowledge the Texas Association of Community Health Centers from which we adapted our Hypertension Patient Sample Dialogue.

In the US, 33% - 50% of patients do not take their medications as prescribed, leading to poor health outcomes. In a recent study of diabetes and heart disease patients, patients with poor adherence had significantly higher mortality rates than adherent patients (12.1% versus 6.7%).68

“The number one cause of treatment failure is not wrong diagnosis, not wrong drug choice, but poor adherence.” Shawn Christopher Shea, MD

Factors that Influence Adherence To maximize medication adherence, patients must be convinced of the importance and efficacy of their medication in the management of their disease.

There are a number of factors that influence a patient’s use of their medication:69

Tlab e 39 Factors that Influence Adherence

Social-Behavioral Drug Factors Cost Factors Factors Positive Influences Positive Positive Influences Influences Adherence increases Patients believe their with lower number of Decreased prescription illness is serious and daily doses. copays. the treatment has value. Increases with use of Decreased out of Satisfaction with health subcutaneous injections. pocket expenses for care provider is strong. medications. Family and friends Negative Influences show positive support. Reduced adherence Negative strongly associated with Influences Negative increased severity of Influences side effects. Belief that there are significant Negative social climate. Adherence reduced inconveniences Barriers to care, somewhat by the associated with taking including cost of care, number of medications the medication. regular source of care. taken.

90 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tips to Improve Adherence65,70 • At every visit o Assess adherence and discuss possible barriers to adherence (see table 39, page 90.) o Ask patients to bring their medications to every visit o Reconcile the patient’s medication list with any medications they may be taking that is not on the list • Adjust doses and eliminate unneeded medication, where appropriate • Prescribe once-daily formulations, less expensive generics and longer lasting medication supplies, where appropriate and when possible • Provide tools such as pill boxes and medication logs to help patients remember to take their medication • Many community pharmacists offer education programs and face-to-face counseling to support adherence to medication therapy. Consider working with local pharmacists to provide resources for patients needing additional education support.

TableTlab 40:e Addressing 40 Addressing Common Barriers Common to Medication Barriers Adherence to Medication Adherence

Patient Barrier Provider Response

Communication

“My meds make me feel sick.”  Explain side effects that are common and tell the patient how to handle them (e.g., call you or the pharmacist). If applicable, let the patient know that the medication may make a person feel worse at first, but that the side effect is expected to go away over time.  If possible, replace with another medication with a ma a D I mpr n different side-effect profile. ia d n  For medications in which side effects persist, suggest be

ag s ov t

ways to manage them, such as take with food (for elf e e

nausea) or before bed (for dizziness) or stay well i s m n

g hydrated and eat a fiber-rich diet (for constipation). car en

 Discuss the long-term benefits of taking medicine. Ty t

e p

e 2 “I feel fine so I don’t need to  Explain to the patient that, unlike antibiotics, many take the medicine.” chronic disease medications don’t make you feel different even when they are working.  Reinforce that the medication will help prevent future illness or medical complications.  Remind the patient that many silent diseases like high blood pressure or diabetes can put patients at risk for heart attack or stroke.

Complexity

“It’s too hard to remember all  Determine whether any medications the patient is on can those pills.” be safely discontinued.  Prescribe a long-acting formulation if appropriate.  Determine whether the patient can take a combination pill.  Review patient medication reminder tools.

Cost

“It costs too much.”  Switch the patient to an equally effective generic or less expensive medication if possible.  Be sure that the patient is not taking unnecessary medications.  Provide prescription assistance program resources.

For a copy of My Medication Log go to chapter 6, page 137.

The practice and the patient visit provide opportunities for improving the care of patients with diabetes through planned and coordinated approaches. What follows are suggestions to reorganize the practice, promote a more prepared and proactive team and build more informed and engaged patients.

Office Systems • Identify and train clinical and office staff in their role as members of the diabetes care team. o Consider training medical office staff as Diabetes Care Coordinators (http://www. caldiabetes.org and search “Diabetes Care Coordinator Program”) • Implement standing orders for common problems or patient conditions • Hold a daily huddle prior to the opening of the practice between the healthcare provider and the medical office staff to review the schedule and communicate known updates and issues. Limit huddles to seven minutes or less. This keeps the meeting focused. • Trained medical assistants can, among other roles: o Prepare routine lab slips prior to patient visits. This will save time during the visit. o Perform routine diabetic foot exams, or have patients remove their socks and shoes upon entering the exam room. o Perform depression screenings on all patients with diabetes. o Review the patient record to ensure lab results, test results and notes from other physicians are in the patient’s record.

Chart Prompts • Help patients set self-management goals and provide a goals worksheet and daily log. • Develop a follow-up system to check in with patients in the monitoring of their diabetes and in implementing behavior changes. • When a prescription is given, set up a reminder system in the office to check with the patient within three days to see if the prescription was filled and whether the patient has any questions about the medicine. • Know your local community resources and refer the patient when needed. • Keep a cheat sheet of the diabetes medication copays for health plans common in your practice. Keep a copy in each exam room for consideration in prescribing and be sure to check for updates intermittently. • Provide information on pharmaceutical company medication assistance programs to patients who may need help in covering the cost of their medications. A listing of these resources is available on the CMA Foundation’s web site at www.thecmafoundation.org/projects/aped/. • Ask the patient about medication cost issues. If you don’t ask, you often won’t be told.

E xam Rooms/Waiting Area • Post a reminder list of proper procedures for patients with diabetes o (Example: Check the charts/electronic records of patients with diabetes in the morning before visits to review whether patient’s labs are up to date, pre-fill any needed lab slips, etc.).

92 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 • Post a reminder or checklist, visible to the appointment desk staff, providing procedural reminders for visits of patients with diabetes o (Examples: Place visit planner or flow sheet into charts, remind patients with diabetes to bring in all their prescription bottles for their next visit, etc.). • Implement regular staff meetings with the entire care team (including the healthcare provider, front desk staff and back office medical staff). Use this time to assess the office systems and to brainstorm and review changes to the management of patients with diabetes. • Staff conducts “messenger activities” (phone calls, emails) regarding appointments, health maintenance, labs and referrals. This activity can also include active reminders, follow ups and encouragement to get existing patients to participate in care.

Building the Diabetes Care Team • Attach foot exam results to charts. • Keep flow sheets and/or visit planners in the medical record to guide visits and ensure that the proper exams and measures are recorded. • Maintain a list in the patient’s chart of their prescribed medications in order to follow up and discuss medication adherence during each visit. • Highlight out of range values for blood pressure, glucose and lipids. • Consider color-coding charts of patients with diabetes. • If the office uses electronic records or has a disease registry ensure the staff reviews and updates the registry regular. Reports on the collected data should be produced and review regularly ma a D I mpr n • Record the patient’s language and race/ethnicity in the medical record. Knowing the patient’s ia d n be

ag s

preferred language prior to the visit will help the office coordinate interpreter services. ov t elf e e i s m Charting the patient’s race or ethnicity will also help office staff to consider the cultural n

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framework for how diabetes and cardiovascular disease is viewed by the patient, identify Ty t e health disparities and can act as a flag in assessing for risk factors. p e 2

Patient Activation/Support • Place educational posters in patients line of sight o The information displayed can empower patients to ask questions and/or remind healthcare professionals of routine care • Have a brochure rack including diabetes-focused topics. • Information should be provided in multiple languages.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 93 94 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

Patient Resources 6 General Care and Management • Your Diabetes Care Team, English, Spanish • Ask Doctor, English, Spanish • Diabetes Health Record, English, Spanish, Chinese • My Health Goal, English, Spanish • Help Loved Ones, English Assessing Risk and Prevention of Diabetes • Tips to Help You Stay Healthy • ADA Risk Test, English, Spanish, Chinese Glycemic Control • Know Your Blood Sugar, English, Spanish • Symptoms Hypoglycemia, English, Spanish • Blood Glucose Log, English Insulin Management • Myths/Fact Insulin, English, Spanish • Mealtime Insulin, English Diabetes and Cardiovascular Disease • Take Care of Your Heart, English • How to Take Care of Your Heart, Spanish • Diabetes, Smoking, and Your Health, English, Spanish Neuropathy • Diabetes & Nerve Damage, English, Spanish Nutrition • Protect Your Heart, English, Spanish • Cholesterol/Fat, English, Spanish • Portion Size, English, Spanish E xercise • All About Physical Activity, English, Spanish • Physical Activity You Need, English Medication Adherence • Med Adherence Myth/Facts, English • My Medication Log, English

Note: All of these materials can be found online in the CMA Foundation’s Multicultural Patient Education Database (MCPED) at http://www.thecmafoundation.org/PEM/application/ Default.aspx. In the MCPED, you will find many of these materials in a variety of languages, where available.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 95 96 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Your Diabetes Care team More than one person may help you control your diabetes. The people who work with you may often be called your Diabetes Care Team. Knowing who these people are and what they do may help you when you visit the doctor’s office, clinic, or hospital.

Doctor: Helps you develop your diabetes care plan. May take care of all your health care needs or only treat diabetes. A doctor with special training in treating people with diabetes is called an endocrinologist (en doe krin AHL uh jist).

Diabetes Educator or Nurse: Your guide for good diabetes self-care. Teaches you how to control your blood sugar, use your meter, avoid high and low blood sugar problems, and much more.

Dietitian (die uh TISH un): Helps you create and follow a meal plan that is right for you.

Pharmacist: Answers questions about your medicine. Fills your prescriptions. Eye Doctor or Ophthalmologist (ahp tha MAHL uh jist): Checks your eyes to help you avoid problems. Treats eye disease.

Foot Doctor or Podiatrist (po DIE uh trist): Treats injuries of the foot. r TI P a Trims toenails, if you cannot do it yourself. e s ou Keep your appointments! en rc t

Your Diabetes Care Team e

is there to help. s ! Cut this out and save it to remind you of your appointments. Appointment With Date Time

Puede que más de una persona le ayuden a controlar su diabetes. Con frecuencia, el grupo de personas que trabaja con usted para controlar su diabetes se conoce como el Equipo para el cuidado de la diabetes. Conocer quiénes son estas personas y lo que hacen, puede ayudarle cuando usted visita la oficina del médico, la clínica o el hospital.

Médico/Doctor: Le ayuda a desarrollar su plan para el cuidado de la diabetes. Puede encargarse de todas sus necesidades de salud o sólo tratar la diabetes. El especialista en diabetes se conoce como endocrinólogo.

Educador en Diabetes o Enfermero: Su guía para un buen cuidado de la diabetes. Le enseña cómo controlar su azúcar en la sangre, usar su glucómetro, prevenir problemas de niveles altos o bajos de azúcar en la sangre y mucho más.

Dietista/Nutricionista: Le ayuda a crear y seguir un plan de comidas adecuado para usted.

Farmacéutico: Contesta sus preguntas sobre sus medicinas. Despacha sus recetas.

Oftalmólogo o Especialista en ojos: Le revisa los ojos para evitar problemas. Trata las enfermedades de los ojos.

Podiatra o Especialista en pies: Trata las lesiones en los pies. Le corta las uñas si usted no puede hacerlo solo. ¡No olvide sus citas médicas! Su Equipo para el cuidado de la diabetes está para ayudarlo. ! Corte y guarde como recordatorio de sus citas médicas. Cita con Fecha Hora

98 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 CareTeamSP.indd 1 8/5/09 11:35:49 PM Questions to Ask My Doctor Preguntas a mi doctor About My Diabetes sobre mi diabetes

My Test Results Mi Resultados de Examen

Lab Test Result Date Due/Target Examen Resultado Fecha Cada cuándo/Mejor nivel 2 times a year/ 2 veces al año/ 7% or 7% o menos less A1C A1C

~ Ask your doctor what your target numbers 1 time a e óptimo de A1C, presión de la sangre are for A1C, blood pressure & cholesterol. s year y colesterol. 1 vez al año ~ Tell your doctor if you have other worries Foot Exam Examen de ~ Si usted tiene otras preguntas o si se los pies or if you feel sad most of the time. * Recommended by the American Diabetes Association (ADA) siente triste gran parte del tiempo, * Recomendación de la American Diabetes Association (ADA) hable con su doctor. ~ It is important to have dental care at least Visit www.lumetra.com/diabetesandlatinos/resources Para obtener una copia electrónica de esta twice year. to print another copy to keep in your wallet. ~ Es importante visitar al dentista por tarjeta de bolsillo, visite Viva la Vida en internet: lo menos dos veces al año. www.lumetra.com/diabetesandlatinos/resources.

Este documento fue hecho posible por el contrato de Lumetra con los Centros de Servicios para Medicare y This document was made possible by Lumetra’s contract with the Centers for Medicare & Medicaid Medicaid (CMS), una agencia del Departamento de Salud y Servicios Humanos de Estados Unidos, número Services (CMS), an agency of the U.S. Department of Health and Human Services, contract number de contrato 500-02-CA02. Los contenido presentado no necesariamente reflejan la política de CMS. 500-02-CA02.The contents presented do not necessarily reflect CMS policy. 7SOW-CA-USPMR-04-03 tome control de su diabetes 7SOW-CA-USPWM-04-03 tome control de su diabetes

My Test Results Mi Resultados de Examen

Lab Test Result Date Due/Target Examen Resultado Fecha Cada cuándo/Mejor nivel 2 times a year/ 2 veces al año/ 7% or 7% o menos less A1C A1C

1 time a year/ Preguntas a mi doctor 1 vez al año/ Questions to Ask My Doctor Less than Menos de 100 LDL – Cholesterol 100 El ABC del cuidado de la diabetes Colesterol - LDL The ABC’s of Diabetes Care Every ~ ¿Cuál es mi nivel de A1C? ~ How is my A1C? When do I need the Visit/ ¿Cuándo necesito repetir el examen? En cada visita/ test again? Less than ~ ¿Cuál es mi presión de la sangre? Menos de ~ How is my Blood pressure? Blood Pressure 130/80 ~ ¿Cuál es mi nivel de colesterol? Presión de 130/80 la sangre ~ How is my Cholesterol? 1 time a Otras preguntas importantes year 1 vez al año Other Important Questions ~ ¿Me va a revisar los pies hoy? Riñones ~ Will you check my feet today? Microalbumin ~ ¿Necesito el examen de los ojos? Proteína en ~ Do I need an eye exam? ~ ¿Dónde puedo tomar clases sobre la orina ~ Where can I attend diabetes 1 time a la diabetes? year education classes? 1 vez al año Dilated Eye Exam Recuerde… Examen especial Remember… ~ Pregunte a su doctor sobre su nivel de los ojos ~ Ask your doctor what your target numbers 1 time a óptimo de A1C, presión de la sangre are for A1C, blood pressure & cholesterol. year y colesterol. 1 vez al año ~ Tell your doctor if you have other worries Foot Exam Examen de ~ Si usted tiene otras preguntas o si se los pies or if you feel sad most of the time. * Recommended by the American Diabetes Association (ADA) siente triste gran parte del tiempo, * Recomendación de la American Diabetes Association (ADA) hable con su doctor. ~ It is important to have dental care at least Visit www.lumetra.com/diabetesandlatinos/resources Para obtener una copia electrónica de esta twice year. to print another copy to keep in your wallet. ~ Es importante visitar al dentista por tarjeta de bolsillo, visite Viva la Vida en internet: lo menos dos veces al año. www.lumetra.com/diabetesandlatinos/resources.

100 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes Health Record Diabetes Health Record Discuss these Basic Guidelines for Diabetes Care Your Name with your diabetes care provider and use this to record your results. Fold to fit into your wallet. Diabetes Care Provider Take charge of your diabetes! Review Blood Diabetes Care Provider Telephone Sugar Records Date: (every visit) Medical Record Number Target (pre-meals):

Blood Pressure Date: (every visit) Target: Value:

Weight Date: (every visit) All people with diabetes Target: Value: need to learn diabetes Foot Exam Date: (every visit) self-care skills. A1C Date: Blood test to measure past 3 mos. blood sugar level (every 3 months) Value: Target:

Microalbuminuria Date: Urine kidney test (every year) Take Charge of Your Diabetes! Target: Value:

Dilated Eye Exam Date: (every year) All people with diabetes need to be actively involved in Dental Exam Date: managing their diabetes. Do you know what tests you (every six months) need to take care of your health and help you manage Blood tests to measure "fats" your diabetes? The Diabetes Health Record will help important to heart disease you keep track of the basic tests you need and how often you need them. It will also help you to record and Cholesterol Date: remember the results of these tests. (every year) Target: Value:

Triglycerides Date: The Diabetes Health Record is based on the Basic Guidelines for (every year) Value: Diabetes Care developed by the Diabetes Coalition of California, in r TI P Target: a collaboration with the California Diabetes Program, American e s ou HDL / LDL Date: Diabetes Association, and the Juvenile Diabetes Research en Foundation International. rc (every year) t Target: Value: e

s Flu Shots Date: (every year) Pneumonia Vaccine (at least once/ask Dr.) Other Juvenile Diabetes Research Foundation International

The Basic Guidelines for Diabetes Care, Discuss these issues regularly with your health care provider Diabetes Health Record (14 languages) and the Take Charge! to improve your diabetes management skills: training tools can be downloaded at: • Smoking Counseling • Hypoglycemia (low sugar) • Medications • Hyperglycemia (high sugar) www.caldiabetes.org • Nutrition Therapy • Sick Day Rules (916) 552-9888 • Physical Activity • Psychosocial Issues • Weight Management • Pre-pregnancy Counseling • Complications • Pregnancy Management • Aspirin Therapy • Dental Exams, twice yearly COPYRIGHT INFORMATION The Diabetes Coalition of California maintains copyright protection If you smoke and want to quit, call the California Smoker’s Helpline over this product. However, it may be reproduced with the citation: 1-800-NOBUTTS or 1-800-662-8887 “Developed by the Diabetes Coalition of California, the California Note: You may require other tests that are not listed. Diabetes Program, and the American Diabetes Association.” 2006

Hable sobre estas Guías Básicas para el Cuidado de la Diabetes con su proveedor de servicios y use esta tarjeta para apuntar sus Su nombre resultados. Doble esta tarjeta y guárdela en su billetera. Proveedor de servicios de atención de la diabetes ¡Tome Control De Su Diabetes!

Revisar los análisis del Teléfono del proveedor de servicios de atención de la diabetes azúcar en la sangre (cada visita) Fecha: Número de registro médico Meta: (antes de las comidas):

Presión de la sangre Fecha: (cada visita) Meta: Resultado: Peso Fecha: (cada visita) Meta: Resultado: Toda persona con diabetes Examen de los pies Fecha: (cada visita) debe aprender habilidades

A1C Análisis de sangre Fecha: para controlar la diabetes para medir el nivel de azúcar en la sangre de los por si mismo. últimos 3 meses (cada 3 Resultado: meses) Meta:

Microalbuminuria Fecha: Análisis de orina-riñón (cada año) Meta: Resultado: ¡Tome Control De Su Diabetes! Examen de la vista con dilatación Todas las personas con diabetes necesitan participar (cada año) activamente en el manejo de su diabetes. ¿Sabe usted Examen de los qué pruebas y análisis necesita para cuidar su salud y dientes Fecha: para ayudar a manejar su diabetes? El Registro de (cada seis meses) Salud de Diabetes le ayudará a recordar las pruebas y análisis básicos que necesita y con qué frecuencia Análisis de sangre para medir las "grasas" importantes deben de hacerse. También le ayudará a anotar y para las enfermedades del corazón acordarse de los resultados de estas pruebas y análisis. Colesterol Fecha: (cada año) Meta: Resultado:

Triglicéridos Fecha: El Registro de Salud de Diabetes está basado en Las Guías (cada año) Básicas para el Cuidado de la Diabetes desarrolladas por la Meta: Resultado: Diabetes Coalition of California, en colaboración con el California Diabetes Program, la American Diabetes Association y la HDL / LDL Fecha: Juvenile Diabetes Research Foundation International. (cada año) Resultado: Meta: Vacunas contra la Fecha: gripe (cada año) Vacuna contra la neumonía (por lo menos una vez/pregunte a su doctor) Otro Juvenile Diabetes Research Foundation International

Hable regularmente sobre estos temas con su proveedor de Para ordenar Las Guías Básicas para el Cuidado de la Diabetes, el servicios de atención de la salud para mejorar sus habilidades para Registro de Salud de Diabetes y el instrumento de entrenamiento el manejo de la diabetes: ¡Tome Control!, visite: • Asesoramiento sobre el cigarrillo • Hiperglicemia (alto nivel de azúcar) www.caldiabetes.org • Medicamentos • Reglamentos sobre días de ausencia • Terapia de alimentación por enfermedad (916) 552-9888 • Actividad física • Temas psicosociales • Control del peso • Asesoramiento anterior al embarazo Información sobre los derechos de autor: • Complicaciones • Manejo del embarazo La Diabetes Coalition of California mantiene derecho de autor sobre • Terapia de aspirina • Exámenes dentales, dos veces al año esta publicación. Sin embargo, puede ser reproducido con la • Hipoglicemia (bajo nivel de azúcar) mención: “Desarrollado por la Diabetes Coalition of California, el Para dejar de fumar llame a la Línea de Ayuda para Fumadores de California California Diabetes Program y la American Diabetes Association.” 1-800-4 56-6386 Nota: Es posible que necesite pruebas que no figuran en la lista. SPANISH 2006

102 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 糖尿病健康記錄卡糖尿病健康記錄卡請和您的糖尿病醫護人員討論

以下的《糖尿病治療的基本原則》並以此卡記錄結果。把它摺起來放進皮夾中。您的姓名掌握您的糖尿病治療！

檢閱血糖記錄提供糖尿病治療的醫護人員 (每次就診) 日期: 目標 (飯前):

血壓日期: 提供糖尿病治療的醫護人員電話 (每次就診) 目標: 數值: 醫療記錄號碼體重日期: (每次就診) 目標: 數值: 足部檢查日期: (每次就診) 所有糖尿病病人都需學習 A1C 日期: 測量過去 3 個月糖尿病的自我護理技巧血糖水平的血液測試數值: (每 3 個月) 目標:

Microalbuminuria 日期: 尿腎測試掌握您的糖尿病治療！ (每年) 數值: 目標:

擴瞳眼睛檢查日期: (每次就診) 所有糖尿病患者都需要積極掌握自己的治療。牙科檢查您是否知道為了保持健康並治療您的糖尿病，日期: 您需要接受哪些測試？糖尿病健康記錄卡 (每六個月一次) 將協助您了解需要接受哪些基本測試以及測試的次數。測量對於心臟病此卡也能幫助您記錄並記住這些測試的結果。重要的脂肪數據

膽固醇日期: (每年) 這份糖尿病記錄卡是根據《糖尿病治療的基本原則》而編寫。數值: 目標: 《糖尿病治療的基本原則》是由 Diabetes Coalition of California 與甘油三酸酯日期: California Diabetes Program、 American Diabetes Association 以及 (每年) Juvenile Diabetes Research Foundation International 合作制定。 r TI P a 目標: 數值: e s ou 高密度脂蛋白/ 低日期: en rc t

密度脂蛋白

數值: e (每年) 目標: s 流感注射日期: (每年) Juvenile Diabetes Research Foundation International 肺炎疫苗 (至少一次/請向醫生諮詢) 《糖尿病治療的基本原則》、其他「糖尿病健康記錄卡」和「掌握您的糖尿病治療！」訓練工具可從以下網站下載：請定期與您的醫護人員討論以下問題，以提高掌握糖尿病的技巧： www.caldiabetes.org • 戒菸諮詢 • 低血糖 (916) 552-9888 • 藥物 • 高血糖 • 營養治療 • 病日規則 • 體育活動 • 心理社會問題著作權資訊: • 體重控制 • 孕前諮詢 Diabetes Coalition of California 對本出版物享有著作權保護。 • 併發症 • 妊娠護理但是只要註明「由 Diabetes Coalition of California, the California • 阿斯匹靈（Aspirin）療法 • 每年檢查兩次牙齒 Diabetes Program and the American Diabetes Association 如果您希望協助戒菸，請致電加州抽煙者協助專線聯合制定」的字樣，就可以複製本出版物。（California Smoker’s Helpline）1- 800-838-8917

注意：您可能還需要做此卡未列出的其他測試。 Chinese 2007

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 103 My Health Goal

Eat a Healthy Diet Be Physically Active Take My Medicine Other

Monitor My Blood Limit Sugar-Sweetened Limit Alcohol Stop Smoking Sugar and/or Beverages Blood Pressure

One way I want to improve my health is (example: take my medicine):

My goal for this week is (example: take my medicine the way the doctor prescribed):

When I will do it (example: every day): ______

Where I will do it (example: in the bathroom after I brush my teeth): ______

How often I will do it (example: once a day as prescribed):______

What might get in the way of my plan (example: I may forget):

What I can do about it (example: put my pill box next to my toothbrush to remind me):

How confident am I that I can reach this goal: circle one* 012345678910 Not A 50/50 Very Totally at all little confident

Follow-up plan (how and when): ______

* Continue working on confidence in reaching goal until at least an ‘8’. HPD1X25933 – 3.10

Patient Copy

104 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Mi meta de salud

Comer una Ser activo Tomar mis Otro dieta saludable físicamente medicamentos

Monitorear mi Limitar las bebidas Limitar el Dejar de fumar azúcar en sangre azucaradas alcohol y/o presión arterial

Una manera en la que quiero mejorar mi salud es (ejemplo: tomar mis medicamentos):

Mi meta para esta semana es (ejemplo: tomar mis medicamentos como lo recetó el médico):

Cuándo lo haré (ejemplo: todos los días): ______

Dónde lo haré (ejemplo: en el baño después de lavarme los dientes):______r TI P a e s ou Con qué frecuencia lo haré (ejemplo: una vez al día como fue recetado): ______en rc t

Qué impedirá mi plan (ejemplo: puedo olvidarme): e s

Qué puedo hacer al respecto (ejemplo: poner mi caja de pastillas al lado de mi cepillo dental para recordarme):

Qué tan seguro estoy de poder lograr esta meta: marque una* 012345678910 No, Un poquito 50/50 Muy seguro Totalmente en absoluto seguro seguro

Plan de seguimiento (cómo y cuándo): ______

* Continúe trabajando en su determinación de lograr la meta hasta alcanzar un ‘8’. HPD1X25934 – 3.10

Copia del paciente

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 105 Help a Loved One with Diabetes There are many things you can do to help your loved one—a family member or friend—with diabetes. Use these tips to get started today. Learn about diabetes. There is a lot to learn about living well with diabetes. Use what you learn to help your loved one manage his or her diabetes. • Join a support group about living with diabetes. Check with your doctor, hospital, or area health clinic. • Read about diabetes online. For help go to www.YourDiabetesInfo.org • Ask your loved one’s diabetes health care team how you can learn more. Talk to your loved one about coping with diabetes. Robert’s goal is to be more • What things are hard for him or her to manage? active, so now he joins his • What things are easy? wife walking their dog • Does your loved one set self-care goals? after work each day. • How does he or she stay on track to reach these goals? • How can you help with diabetes care tasks? • Does your loved one feel down sometimes? • What can you do to help him or her feel better? • Does your loved one talk to his or her doctor or other health care team members about feeling down? Find out what your loved one needs. Ask your loved one: • What do I do that helps you with your diabetes? • What do I do that makes it harder for you to manage your diabetes? • What can I do to help you more than I do now? Find ways to help.

Nagging will not help either you or your loved one. Carla helps Daniel maintain When you have found one way to help, add another way. his goal of making healthy food choices by preparing www.YourDiabetesInfo.org or 1-888-693-NDEP (1-888-693-6337) meals at home.

106 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Tips to Help You Stay Healthy

Taking action to manage your diabetes can help you feel good today and stay healthy in the future.

Work with your doctor and other health care team members to make a diabetes care plan that works for you. Follow these four steps.

Step 1: Step 3: Learn About Diabetes Manage Your Diabetes

Diabetes means that your blood glucose (sugar) is too Your diabetes care plan should help you to: high. Diabetes is serious because it can damage your heart, ■ Keep track of your diabetes numbers. blood vessels, eyes, kidneys, and nerves. But you can learn ■ Learn how and when to check your own how to manage it and prevent or delay health problems. blood glucose. ■ Take a class and join a support group about living with diabetes. Check with your health care team, • See what makes your blood glucose go up or down. hospital, or area health clinic. • Go over the test results with your health care team. ■ Read about diabetes online. Use them to manage your diabetes. Go to www.YourDiabetesInfo.org. • Ask how to prevent low blood glucose. ■ Ask your diabetes health care team how you can ■ Be active for 30 to 60 minutes on most days learn more. of the week. Brisk walking is a great way to be active.

■ Stop smoking. r TI P a Step 2: e Call 1-800-QUIT-NOW (1-800-784-8669). s ou en ■

Know Your Numbers rc Eat healthy foods such as: t

Ask your doctor what diabetes target numbers are best • fruits, vegetables, fish, lean meats and poultry, s for you. They may be different from the numbers below. dried peas or beans, lentils, and low-fat or skim milk and cheese ■ A1C measures your average blood glucose level over the past 2 to 3 months.The A1C target for many • whole grain foods such as whole wheat bread and people is below 7. crackers, oatmeal, brown rice, and cereals ■ LDL, or bad cholesterol, builds up and clogs your • food prepared with little added fat, oil, salt, or sugar arteries. The LDL target is below 100. • smaller servings of meat, fish and poultry ■ High blood pressure makes your heart work too • larger servings of fruits and vegetables. hard. The blood pressure target for most people is less than 130/80.

www.YourDiabetesInfo.org or 1-888-693-NDEP (1-888-693-6337)

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 107 Could You Have ························ Diabetes and At-Risk Weight Chart Body Mass Index Not Know It? Height Weight In feet and inches In pounds without Take the Test. Know your Score. without shoes clothing There are 18.2 million Americans with diabetes – and nearly one-third of them (or 5.2 4’ 10” 129 million people) don’t know it! Take this test to see if you are at risk for having diabetes. Diabetes is more common in African Americans, Latinos, American Indian and Alaskan 4’ 11” 133 Native, Asian Americans, and Pacific Islanders. If you are a member of one of these 5’ 0” 138 ethnic groups, you need to pay special attention to this test. 5’ 1” 143 To find out if you are at risk, write in the points next to each statement that is true 5’ 2” 147 for you. If a statement is not true, write a zero. Then add all the points to get your total score. 5’ 3” 152 1. My weight is equal to or above that listed in the 5’ 4” 157 Yes 5 chart. 5’ 5” 162 2. I am under 65 years of age and I get little or no Yes 5 exercise during a usual day. 5’ 6” 167 3. I am between 45 and 64 years of age. Yes 5 5’ 7” 172 4. I am 65 years old or older. Yes 9 5’ 8” 177 5. I am a woman who has had a baby weighing more 5’ 9” 182 Yes 1 than nine pounds at birth. 5’ 10” 188 6. I have a sister or brother with diabetes. Yes 1 5’ 11” 193 7. I have a parent with diabetes. Yes 1 6’ 0” 199 TOTAL 6’ 1” 204 Scoring 3-9 points 6’ 2” 210 You are probably at low risk for having diabetes now. But don’t just forget about it – especially if you are a Hispanic/Latino, African American, 6’ 3” 216 American Indian and Alaskan Native, Asian American, and Pacific Islander. 6’ 4” 221 You may be at higher risk in the future. If you weigh the same or more than the amount Scoring 10 or more points listed for your height, you may be at risk for diabetes. You are at a greater risk for having diabetes. Only your health care provider can determine if you have diabetes. At your next office visit, find out for sure. ·························· Diabetes Facts You Should Know ··························

Diabetes is a serious disease that can lead to blindness, heart disease, strokes, kidney failure, and amputations. It kills almost 210,000 people each year. Some people with diabetes have symptoms and some do not. If you have any of the following symptoms, contact your doctor: • Extreme thirst • Frequent urination • Unexplained weight loss

For more information on diabetes, call 1-800-Diabetes (342-2383) or visit www.diabetes.org. The information contained in the American Diabetes Association (ADA) web site and this risk test is not a substitute for medical advice or treatment, and the ADA recommends consultation with your doctor and health care professional.

(ENGLISH 2005)

108 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 ¿Podría usted ························ tener diabetes Tablas de Riesgo por Peso Indice de masa del cuerpo y no saberlo? Estatura Peso Pies y pulgadas En libras Tome el examen. Conozca el resultado. sin zapatos sin ropa Hay 18.2 millones de Americanos con diabetes – ¡y casí una tercera parte de ellos (o 5.2 millones de personas) no lo saben! Tome este examen para saber si usted está a riesgo 4’ 10” 129 de tener diabetes. La diabetes es más común en los afro-americanos, latinos, nativos americanos y nativos de Alaska, asiáticos-americanos, y los nativos de las Islas del 4’ 11” 133 Pacífico. Los grupos étnicos, necesita tomar atención especial a este examen. 5’ 0” 138 Para saber si esta a riesgo, escriba los resultados a la par de cada oración que sea 5’ 1” 143 cierta para usted. Si una oración no es cierta para usted, ponga un cero. Después sume el total de los resultados. 5’ 2” 147 1. Mi peso es igual o está por encima del indicado en 5’ 3” 152 Si 5 la tabla. 5’ 4” 157 2. Yo tengo menos de 65 años de edad y hago poco Si 5 o ningún ejercicio durante un día normal. 5’ 5” 162 3. Yo tengo entre 45 y 64 años de edad. Si 5 5’ 6” 167 4. Yo tengo 65 años de edad o más. Si 9 5’ 7” 172 5. Yo soy una mujer que tuvo un bebé que pesó más Si 5’ 8” 177 1 de 9 libras al nacer. 5’ 9” 182 6. Yo tengo una hermana o un hermano con Si 1 diabetes. 5’ 10” 188 7. Uno de mis padres tiene diabetes. Si 1 5’ 11” 193 TOTAL 6’ 0” 199 Si su resultado es de 3 a 9 puntos 6’ 1” 204 r TI P a Usted está probablemente a bajo riesgo de tener diabetes por ahora. Pero no lo olvide- 6’ 2” 210 e s ou especialmente si usted es hispano/latino, afro-americano, nativo americano o nativo de en 6’ 3” 216 rc Alaska, asiático-americano, y el nativo de las Islas del Pacífico. Usted puede estar a un t

riesgo más alto en el futuro. 6’ 4” 221 e s Si su resultado es de 10 ó más puntos Si usted pesa lo mismo o más del peso indicado para su estatura, usted puede Usted está a alto riesgo de tener diabetes. Sólo su proveedor de salud puede determinar estar a riesgo de desarrollar diabetes. si usted tiene diabetes. En su próxima cita, averiguese. ·················· Datos Sobre la Diabetes Que Debe Saber ··················

La diabetes es una enfermedad seria que puede conducir a ceguera, enfermedad del corazón, derrame cerebral, mal funcionamiento de los riñones y amputaciones. La diabetes mata más de 210,000 personas cada año.

Algunas personas con diabetes muestran síntomas y algunas personas con diabetes no muestran síntomas. Si usted tiene alguno de los siguientes síntomas, póngase en contacto con su médico: • Sed excesiva • Orina frecuentemente • Pérdida de peso inexplicable

Para obtener mas información, llame gratis al 1-800-Diabetes (342-2383) o visite nuestra página en el Internet, www.diabetes.org. La información contenida en este sitio web de la Asociación Americana de Diabetes y esta prueba de riesgo no es un sustituto de consejo ó tratamiento médico, y la AAD recomienda que consulte con su médico ó profesional de salud.

(SPANISH 2005)

請回答下面的問卷，看看總分是多少。

回答下面的問卷，看看您是否有患糖尿病的危險。糖尿病在非裔美國人美國糖尿病協會、拉美人、美洲土著人、美國亞裔以及太平洋島居民中很常見。如果您屬於上述任何一個族裔，您就需要認真地，準確地回答下面的問題。危險體重表身高體重對應表（BMI）請認真閱讀每一道題，如果某道題符合您情況，就在“是＂上畫一個圓圈，並把“ 是＂後邊的分數抄在上。如果該問題不符合您不穿鞋身高 He 體重（減衣服重量）情況，就在上寫“0＂。最後，把每道題的分數加起來，得出單位﹕ 英尺單位﹕ 磅 4' 10" 129 總分，並將其填寫在“總分＂格內。 4' 11" 133 5' 0" 138 1. 我是一位女士，曾生過出生時體重超過9磅的孩子。是 1 5' 1" 143 5' 2" 147 2. 我的兄弟姐妹中有人有糖尿病。是 1 5' 3" 152 5' 4" 157 5' 5" 162 3. 我的父親或母親有糖尿病。是 1 5' 6" 167 5' 7" 172 4. 我的體重等於或超過與我身高相對應的體重數 5' 8" 177 （請在右邊的表里找到與你身高相對的體重數）。是 5 5' 9" 182 5' 10" 188 5. 我年齡在65歲以下，而且我很少或根本不運動。是 5 5' 11" 193 6' 0" 199 6. 我的年齡在45歲到64歲之間。是 5 6' 1" 204 6' 2" 210

6' 3" 216 7. 我的年齡是65歲或以上。是 9 6' 4" 221

總分﹕ 如果您的體重等於或超過此表中與您的身高相對應的體重數，那麽您可能有患糖尿病的風險。總分數爲10分或更高您患糖尿病的風險很高。只有您的醫生才能爲您進行核實，看您是否患糖尿病。儘快去見醫生，查明您是否有糖尿病。

總分數爲3-9分您現在患糖尿病的風險可能較低，但是您也不能掉以輕心。您可以通過下列方式使自己患糖尿病的風險始終保持在很低的水平：減輕體重（如果您體重超標的話）；多作運動；吃用較多水果和蔬菜做成的低脂肪食品；食用全麥食品。 ⋯⋯⋯⋯⋯⋯⋯⋯您應⋯該⋯瞭 ⋯解的⋯糖⋯尿病⋯基⋯本 ⋯知識⋯⋯⋯⋯⋯⋯⋯⋯

糖尿病是一種很嚴重的疾病，它能導致失明，心臟病，中風，腎衰竭以及截肢。如果您符合下列情況，那麽您患糖尿病的風險較高： ‧ 45歲或以上 ‧ 體重超標 ‧ 有高血壓 ‧ 有糖尿病家族病史欲瞭解更多信息，請打電話 1-800-DIABETES (342-2383) 或登陸網站 www.diabetes.org

110 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Know Your Blood Sugar Numbers

If you have diabetes, keeping your blood glucose (sugar) numbers in your target range can help you feel good today and stay healthy in the future.

There are two ways to measure blood glucose.

The A1C is a lab test that measures your average blood glucose level over the last 2 to 3 months. It shows 1 whether your blood glucose stayed close to your target range most of the time, or was too high or too low. Self-tests are the blood glucose checks you do yourself. They show what your blood glucose is at the 2 time you test. Both ways help you and your health care team to get a picture of how your diabetes care plan is working.

About the A1C test About self-tests for blood glucose

Why should I have an A1C test? The A1C tells Why should I do self-tests? Self-tests can help you you and your health care team how well your diabetes learn how being active, having stress, taking medicine and care plan worked over the last 2 to 3 months. It also eating food can make your blood glucose go up or down. helps decide the type and amount of diabetes medicine They give you the facts you need to make wise choices as you need. you go through the day.

What is a good A1C target for me? For many Keep a record of your results. Look for times when your

blood glucose is often too high or too low. Talk about your r TI P

people with diabetes, the A1C target is below 7. You a e s

results with your health care team at each visit. Ask what ou and your health care team will decide on an A1C target en rc that is right for you. If your A1C stays too high, it may you can do when your glucose is out of your target range. t

increase your chances of having eye, kidney, nerve, and s How do I check my blood glucose? Blood glucose heart problems. meters use a small drop of blood to tell you how much How often do I need an A1C? You need an A1C at glucose is in your blood at that moment. Ask your health least twice a year. You need it more often if it is too high, care team how to get the supplies you need. They will if your diabetes treatment changes, or if you plan to also show you how to use them. become pregnant.

What if I plan to become pregnant? Talk with “I bring my self-test your doctor before you get pregnant. Your doctor can record when I visit my help you reach an A1C target that allows a healthy baby doctor. We talk about to develop. If you are already pregnant, see your doctor what makes my blood right away. glucose go up or down and what to do about it.”

omar control de su diabetes puede ayudarlo a sentirse mejor y mantenerse saludable. Las investigaciones T indican que al mantener un nivel normal de glucosa sanguínea (azúcar en la sangre), usted reducirá sus posibilidades de tener complicaciones de los ojos, los riñones y los nervios. Para controlar su diabetes, usted tiene que saber cuál es su nivel de glucosa sanguínea y cuáles deberían ser sus metas.

Hay dos pruebas diferentes para medir la glucosa sanguínea.

1 La prueba A1C refleja el nivel 2 Una prueba de glucosa sanguínea promedio de glucosa en su sangre que usted mismo se puede hacer durante los últimos 3 meses. Es la utilizando una gota de sangre y un mejor manera de saber cuán bien aparato, que mide el nivel de glucosa controló su glucosa sanguínea en su sangre en el momento de durante ese período. Antes se la chequearla. Esto se llama el auto llamaba la prueba de la hemogoblina control de la glucosa sanguínea A 1 C o H-b-A-1-C. (“self-monitoring of blood glucose” o SMBG en inglés).

Usted y su equipo de atención médica necesitan los resultados de ambas pruebas, la A1C y la del auto control de la glucosa sanguínea, para saber mejor cómo está el control de su glucosa sanguínea (glucemia).

1-800-438-5383 www.ndep.nih.gov

El Programa Nacional de Educación sobre la Diabetes (NDEP), parte del Departamento de Salud y Servicios Humanos de los Estados Unidos, es un programa conjunto de los Institutos Nacionales de la Salud (NIH), los Centros para el Control y la Prevención de Enfermedades (CDC), y más de 200 organizaciones asociadas.

Publicación NIH No. 98-4350 (S). Impreso en septiembre del 2005

112 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Symptoms of Hypoglycemia (Low Blood Sugar)

CA U S E S : Too little food, too much insulin or diabetes medicine, too much physical activity

ON S E T: Sudden, may progress to insulin shock

BL O O D SU G A R : Below 70 mg/dL

SHAKING RAPID HEADACHE HEARTBEAT

SWEATING IMPAIRED ANXIOUS DIZZINESS VISION

WEAKNESS, IRRITABLE HUNGER

FATIGUE r TI P a e s ou en rc t

e To Treat Hypoglycemia s

CHECK BLOOD SUGAR DRINK CHECK BLOOD SUGAR WITHIN 30 MIN. If you are at 4oz. of juice or In 15 minutes. after symptms end, eat 70 mg/dl or less... 8oz. skimp milk, If symptoms don’t a snack of a peanut or eat several stop, call your doctor. butter or meat sandwich hard candies. and a glass of milk.

Symptoms of Hypoglycemia Translation of this publication was supported by HRSA HCAP Grant # G92OA02204. ©2006 The Whittier Institute for Diabetes Permission granted by The Whittier Institute for Diabetes to copy for patient education purposes. For additional information see www.whittier.org

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 113

SINTOMAS DE LA HIPOGLUCEMIA (Glucosa Baja en la Sangre)

CAUSAS: Muy poca comida, mucha insulina o medicina para la diabetes, demasiada actividad física INICIO: Repentino, puede avanzar a choque insulínico GLUCOSA EN LA SANGRE: Por debajo de 70 mg/dl.

TEMBLORES RITMO CARDIACO RÁPIDO DOLOR DE CABEZA

TRANSPIRACIÓN VISIÓN BORROSA ANSIEDAD MAREO

HAMBRE DEBILIDAD, FATIGA IRRITABILIDAD

Para Tratar la Hipoglucemia

MIDA SU NIVEL BEBA REVISE SU NIVEL DENTRO DE LOS DE GLUCOSA 4 oz. de jugo ú DE GLUCOSA SIGUIENTES 30 MINS. Si tiene 8 oz. de leche descremada Si en 15 minutos después de que se quitan 70 mg/dL o menos… o coma varios no se quitan los los síntomas, coma un caramelos síntomas, llame a bocadillo de un sándwich su médico. de crema de cacahuate o de carne y un vaso con leche. ©2006

114 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Insulin Insulin mm/dL mm/dL

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This resource was created to dispel common misconceptions about insulin. Insulin does not cause diabetes complications such as amputations, blindness, and kidney failure. Poorly controlled diabetes can lead to these complications, not the use of insulin.

What is Diabetes? Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles (American Diabetes Association, ADA).

The Importance of Insulin Insulin is a vital part of the body’s food use. In a healthy body, the stomach and digestive system break down much of the food we eat into glucose, a type of sugar. This glucose is released into the bloodstream. All the cells of the body use glucose for energy. Insulin acts as a key, unlocking the cells and enabling glucose to enter and provide fuel and energy. In people with diabetes, that key is gone. Without insulin, there is no way for the glucose to travel from the blood into individual cells. Then two things happen: the cells begin to starve, and the level of glucose in the blood rises to unhealthy levels (ADA).

Insulin Options Many people give themselves insulin shots using a syringe. Other choices are insulin pens and pump therapy. For more information about different types of insulin, consult with your health care provider.

Types of Diabetes: Pre-diabetes is a term used for people who are at risk of developing diabetes. People with pre-diabetes have higher-than-normal blood glucose level but the levels are not high enough for a diagnosis of type 2 diabetes (ADA).

Type 2 diabetes results from insulin resistance, a condition in which the body fails to properly use insulin, combined with relative insulin deficiency. Approximately 90-95% of Americans who are diagnosed with diabetes have type 2 diabetes (ADA).

Type 1 diabetes results from the body's failure to produce insulin, the hormone that "unlocks" the cells of the body allowing glucose to enter and fuel them. It is estimated that 5-10% of Americans who are diagnosed with diabetes have type 1 diabetes (ADA).

Gestational diabetes. Pregnant women who have never had diabetes before but who have high blood sugar levels during pregnancy are said to have gestational diabetes (ADA).

Adopted from: New Beginnings “A Discussion Guide for Living Well with Diabetes” Based on the Themes from the Debilitator. DHHS, NDEP, CDC and NIH American Diabetes Association

116 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 MITOS Y REALIDADES SOBRE LA INSULINA Este documento fue creado como un esfuerzo para clarificar algunas de las creencias más comunes sobre la insulina. A pesar de muchos esfuerzos de disminuir el temor y creencias sobre la insulina, el uso de esta continua siendo visto por mucha gente como causante de complicaciones de diabetes como amputaciones, ceguera, problemas con los riñones, etc. Todas estas complicaciones comúnmente pueden ser causadas por diabetes no controlada y no por el uso de la insulina.

¿Qué es la Diabetes? La diabetes es una enfermedad la cual previene que el cuerpo no produzca insulina o no la pueda usar adecuadamente. La insulina es una hormona la cual es necesaria para convertir azúcar, almidones y otras comidas en energía requerida para que el cuerpo funcione. La causa de la diabetes continua siendo un misterio aunque la genética, (herencia familiar) y factores ambientales como la obesidad y la falta de ejercicio aparentemente juegan un papel (Asociación Americana de la Diabetes, ADA).

La importancia de la insulina La insulina es importante para que nuestro cuerpo pueda usar las comidas como energia. En un cuerpo sano, el estomago y el sistema digestivo convierten las comidas que comemos en glucosa, un tipo de azúcar la cual es transportada por medio de la sangre. Todas las células de nuestro cuerpo utilizan la glucosa como energía. La insulina actúa como una llave para abrir las células para que la entre y sea utilizada como energía. En las personas con diabetes, esta llave no existe y sin la insulina no hay manera para que la glucosa sea transportada de la sangre a dentro de las células. Después dos cosas pasa: las células comienzan a pasar hambre, y el nivel de glucosa en la sangre sube a niveles no saludables (ADA).

Opciones de insulina La mayoría de la gente que usa insulina usa jeringas. Otras opciones de terapia de insulina son plumas y pompas. Para más información sobre tipos y marcas de insulina, favor de r TI P

consultar con su proveedor de salud. a e s ou en rc Tipos de Diabetes t

Pre-diabetes es un término que se usa para describir a las personas que corren mayor s riesgo de desarrollar la diabetes. Las personas con pre-diabetes tienen un nivel de azúcar en la sangre por enzima de lo normal pero no lo suficientemente alto para que se les diagnostique como diabetes (ADA).

Diabetes tipo 2, ocurre cuando el cuerpo no puede utilizar apropiadamente la insulina. Entre el 90-95% de todos os casos de diabetes son tipo 2 y por lo general en personas adultas. Sin embargo, recientemente este tipo de diabetes esta aumentado de una manera alarmante en niños y jóvenes. Diabetes Tipo 1, antes conocida como diabetes juvenil y resulta cuando el cuerpo no produce insulina.

Adopted from: New Beginnings “A Discussion Guide for Living Well with Diabetes” Based on the Themes from the Debilitator. DHHS, NDEP, CDC and NIH American Diabetes Association

What is mealtime insulin? y Rapid-acting insulin, such as y Pre-mixed insulin, including NovoLog®, Humalog® and Apidra®: Humulin® 70/30, Novolog® Mix 70/30, Insulin keeps blood glucose in Novolin® 70/30, Humalog® Mix 50/50™ balance. If blood glucose levels are ◊ Take just before eating, or up to 15 and Humalog® Mix 75/25™: too high, two types of insulin may minutes after your first bite of food be used to improve blood glucose: ◊ Take only twice a day (usually) ◊ Works quickly; injections must be long-acting and rapid-acting. Long- synchronized with meal time ◊ Is not as flexible as rapid-acting acting insulin helps control blood or regular insulin in terms of meal glucose throughout the day, while y Regular insulin, like Humulin® R timing and food choices rapid-acting insulin manages levels and Novolin® R: at meal time. ◊ Combines two different types of ◊ Take about 30 minutes before insulin in the same bottle Over time, if you take oral diabetes eating ◊ May help cover two meals medications, or are on a once-a-day ◊ Works slower than rapid-acting insulin schedule, such as LANTUS® insulin, but also lasts longer ◊ Lasts longer than rapid-acting or or Levemir®, you may notice higher regular insulin blood glucose levels after meals, or your blood work may show How will taking mealtime insulin affect your lifestyle? increased A1C values. To help you better control your diabetes, Benefits Considerations providers may add a dose of Insulin-injection supplies need to be brought mealtime insulin to your treatment Greater control for meals eaten away from home; insulin plan, taken at breakfast, lunch and pens and travel cases make this easier. dinner. More food choices and Taking insulin at meals does not mean you Are there different types flexibility with timing of can eat whatever you choose; you should still of mealtime insulin? meals and snacks follow a balanced, healthy meal plan. If your health care provider adds You may need to learn how to use a sliding mealtime insulin to your treatment scale plan, or an insulin-to-carbohydrate Easy to use plan, keep in mind there are several ratio, to figure out your dose. Your diabetes types to choose from. Each is team will help you with this. unique, so work with your provider There is a higher risk of low blood glucose if and registered dietitian to determine After-meal blood glucose meals are delayed. Have glucose tablets, gels which kind is right for you. closer to goals or treatments available at all times.

118 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 If you have diabetes, take care of your heart. Having diabetes means you are more likely to have a heart attack or a stroke—but it doesn’t have to—if you take care of your diabetes.

P Over time, high blood glucose (sugar) can hurt organs in your body such as your kidneys and your eyes. High blood pressure can make your heart work too hard. And bad cholesterol, or LDL, builds up and clogs your heart and blood √ vessels. Taking care of your blood glucose, blood pressure, and cholesterol means a x longer and healthier life. ASK YOUR DOCTOR 1 What are my blood glucose, blood pressure, and cholesterol numbers? ᴯ 2 What should they be? 3 What actions can I take to reach my goals?

Use the Diabetes Record Form to write down the answers to these questions. r TI P a

TAKE ACTION NOW e s ou You can live longer, improve your health, and lower your risk of heart disease en rc t

or stroke. e s n Eat foods like fruits, vegetables, beans, and whole grains. n Eat foods made with less salt and fat. n Be active 30 minutes or more each day. n Stay at a healthy weight—by being active and eating the right amounts of healthy foods. n Stop smoking—ask for help or call 1-800-QUITNOW (1-800-784-8669). n Take medicines the way your doctor tells you. n Ask your doctor about taking aspirin. n Ask for help if you feel down or have trouble with stress. n Ask your family and friends to help you take care of your heart and your diabetes.

english · april 2010

¿Le informó su proveedor de atención médica que tiene un alto riesgo de padecer enfermedades del corazón? ¿Usted tiene diabetes? ¿Yatuvo un ataque al corazón? Si es así, es mucho más probable que pueda tener arteriopatía coronaria (un tipo de enfermedad del corazón), un ataque al corazón o un derrame cerebral. Sin embargo, también puede tomar pasos para prevenir o disminuir la posibilidad de tener un ataque al corazón. En estos casos, le resultará útil hacer cambios en su estilo de vida, tales como seleccionar sus alimentos en forma inteligente, mantenerse activo físicamente y tomar medicinas. ¿Cuáles son las causas de las arteriopatías coronarias? Los medicamentos y los cambios en su estilo de vida, pueden Las arteriopatías coronarias ocurren cuando los vasos ayudarlo a prevenir un ataque al corazón. sanguíneos que van al corazón se estrechan o quedan bloqueados debido a depósitos de grasa y otras substancias. Los depósitos luego se pueden desprender y formar un Valores deA1C Mi resultado Mi valor coágulo. Si un coágulo llegara a reducir o bloquear el flujo recomendados por de sangre hacia el corazón, usted podría sufrir un ataque. laADA deseado A1C: menos ¿Qué pasos puedo tomar para prevenir del 7% una arteriopatía coronaria? eAG: menos de Puede reducir sus riesgos prestando atención al ABC de la 154 mg/dl diabetes y tomando decisiones inteligentes respecto a la La B es para la buena presión arterial actividad física y medicamentos. También es útil adelgazar y dejar de fumar. Entre más cerca esté de sus niveles La presión arterial (sanguínea) es la fuerza del flujo de la deseados, mayor es la probabilidad de que pueda prevenir sangre en los vasos sanguíneos. Cuando es alta, el corazón enfermedades del corazón y reducir su riesgo de tener un tiene que trabajar más de lo que debería. Anote aquí su ataque al corazón. resultado más reciente y el resultado al que desea llegar. Valor de presión Mi resultado Mi valor La A es para A1C arterial recomen- dado por laADA deseado La prueba A1C le indica cuál fue el promedio de los niveles de glucosa en la sangre durante los últimos dos a tres meses. Menos de El promedio de glucosa en la sangre se indica de dos 130/80 mmHg maneras: La C es para el colesterol • A1C (como porcentaje) El valor le indicará la cantidad de grasa, o lípidos, que tiene • promedio estimado de glucosa (estimated Average en la sangre. Glucose – eAG) en cifras similares a las lecturas diarias de glucosa en la sangre • El colesterol LDL, también llamado colesterol “malo” puede bloquearle los vasos sanguíneos y ocasionar El cuadro siguiente muestra los niveles recomendados por enfermedades cardiacas. la Asociación Americana de la Diabetes (ADA). Hable con • El colesterol HDL llamado a veces colesterol “bueno” su equipo de cuidado de la salud para determinar qué ayuda a proteger el corazón. valores serían ideales para usted. Anote aquí su resultado • Otro tipo de grasa, los triglicéridos, aumentan su riesgo de más reciente y el valor al que desea llegar. sufrir enfermedades del corazón.

120 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes, Smoking, and Your Health Smoking has severe effects on your diabetes and your health. When you quit smoking, you can have more energy, a longer life, better control of your diabetes, and less chance of a heart attack or stroke. Call the California Smokers’ Helpline – it’s Fast, it’s Free, and it’s Easy: 1-800-NO-BUTTS or 1-800-662-8887

Eyes Smoking can make vision problems worse which can Teeth lead to blindness. Smoking raises your risk of getting gum disease and losing your teeth. Heart Nerves Smokers with diabetes are 11 times Smoking raises your risk of more likely to have a heart attack or nerve damage. This can cause stroke than people who don’t have numbness, pain and problems diabetes and don’t smoke. with digestion. Blood Sugar Smoking raises your blood glucose Feet & Legs (sugar) and reduces your body’s Smoking can lead to serious foot ability to use insulin, making it more and leg problems like infections, difficult to control your diabetes. ulcers, and poor blood flow. Smoking raises your risk of amputation. Cholesterol Many people with diabetes have Kidneys high levels of cholesterol. Smoking Smoking triples your risk of makes this worse by increasing build

getting kidney disease. Drugs that up on artery walls, putting you at

help prevent kidney failure don’t r TI P

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work as well for smokers. s ou en rc t

e Quit Smoking Today! s

Call the California Smokers’ Helpline at 1-800-NO-BUTTS or 1-800-662-8887 Chewing Tobacco: 1-800-844-CHEW

For more information about diabetes: California Diabetes Program at (916) 552-9888 or www.caldiabetes.org American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or www.diabetes.org ©2008 The Regents of University of California. All rights reserved. This material was supported by the Preventive Health and Health Services Block Grant from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 121 La Diabetes, el Fumar, y Su Salud El fumar tiene efectos negativos en su diabetes y su salud. Cuando deje de fumar, usted tendrá más energía, vivirá una vida más larga, controlara mejor su diabetes y tendrá menos riesgos de sufrir un ataque al corazón o de sufrir una embolia. Hable a la Línea de Ayuda para Fumadores – es Gratis, es Rápido y es Fácil: 1-800-45-NO FUME ó 1-800-456-6386 Ojos El fumar hace que sus Dientes problemas de la vista El fumar aumenta el riesgo de empeoren, lo que puede desarrollar enfermedades en las resultar en ceguera. encías y puede perder sus dientes. Nervios Corazón Los fumadores con diabetes son El fumar aumenta el riesgo 11 veces más propensos a sufrir de dañar a sus nervios. Esto un ataque al corazón o de sufrir puede causar entumecimiento, una embolia en comparación dolor y problemas de digestión. con las personas que no tienen diabetes y no fuman. Glucosa (Azúcar) Pies y Piernas En La Sangre Fumar puede causar problemas El fumar aumenta el nivel de glucosa muy serios en sus pies y piernas, (azúcar) en la sangre y disminuye como mala circulación, infecciones la capacidad del cuerpo de usar y úlceras. El fumar aumenta la insulina, haciendo más difícil el el riesgo de amputaciones. control de la diabetes.

Riñones Colesterol El riesgo de desarrollar enfermedades de Mucha gente con diabetes tiene altos los riñones aumenta por tres veces de lo niveles de colesterol. El fumar empeora esta normal cuando uno fuma. Las medicinas para condición aumentando la acumulación de prevenir las complicaciones de los riñones no colesterol en las paredes de las arterias. Esta funcionan muy bien en los fumadores. condición aumenta su riesgo de sufrir un ataque al corazón o de sufrir una embolia. ¡Deje de fumar hoy mismo!

Habla a la Línea de Ayuda para Fumadores de California al 1-800-45-NO FUME ó 1-800-456-6386

Para más información sobre la diabetes: Programa de Diabetes de California: (916) 552-9888 ó www.caldiabetes.org Asociación Americana de Diabetes: 1-800-DIABETES (1-800-342-2383) ó www.diabetes.org ©2008 The Regents of University of California. All rights reserved. This material was supported by the Preventive Health and Health Services Block Grant from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

122 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

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e s Diabetes and NerveDiabetes Damage or no interest in sex? or no interest Do you feel faint or dizzy when stand up? Do you see double or feel pain behind your eyes? Do you have a hard time finishing your meals? Is it difficult to go the bathroom? you having problems with your sexual health, like low Are Do you get sharp pains in your thighs, hips, buttocks or legs? Do your hands or feet ache, burn tingle? Written in collaboration with the UCSF Neuropathy Center. We thank Pfizer, Inc. for their support in developing this material. thank Pfizer, We Written in collaboration with the UCSF Neuropathy Center. CMA Foundation • 3835 N. Freeway Blvd, Suite 100, Sacramento, CA 95834 Phone (916)779-6620 Fax (916) 779-6658 ww w.thecmafoundation.org your nerves healthy by having good control of your blood sugar levels. nerves your Sometimes, diabetes can cause damage to your nerves. This be very painful. What Are Nerves? nerves help you Your a very important part of your body. nerves are Your taste, smell, walk and feel pain. If you have diabetes, can help keep Signs of Nerve Damage The parts of your body. Nerve damage can occur in different most common type of nerve damage occurs in your hands and feet. Doctors call this Diabetic Peripheral Neuropathy (DPN). If you answer yes to any of these questions, may have nerve damage due to diabetes. Head and Eyes: • • Stomach and Intestines: • • Sexual Organs: • Body: Lower • Hands and Feet: •

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 123

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2. 1. Tome Acción Tome ome para ayudarlo a aliviar el dolor debido daño de los nervios. sus medicamentos como indica el médico y esto lo ayudará a proteger los nervios de más daño. buen control de sus niveles de azúcar en la sangre. buen control de sus niveles azúcar en la sangre. Controle T Manténgase

• • • Pida ayuda que puede tener daño a los nervios. Hable con su médico si cree Hay tratamientos disponibles para proteger los nervios de más daño Estos son algunos de los tratamientos: y para controlar el dolor. La diabetes y el daño a los nervios a los daño y el La diabetes ¿Siente que se va desmayar o se marea cuando ¿Siente que se va desmayar o marea se pone de pie? doble o siente dolor detrás de los ojos? ¿Ve dificultad para terminar sus alimentos? ¿Tiene ¿Le es difícil ir al baño? ¿Está teniendo problemas con su salud sexual, como bajo o en el sexo? ningún interés agudos en los muslos, caderas, nalgas o piernas? ¿Siente dolores ¿Le duelen, le arden o siente hormigueo en las manos pies? Escrito en colaboración con el Centro de Neuropatía de UCSF. Le agradecemos a Pfizer, Inc. por su apoyo en desarrollar este material. Le agradecemos a Pfizer, Escrito en colaboración con el Centro de Neuropatía UCSF. (916)779-6620 • Fax (916) 779-6658 www.thecmafoundation.org CMA Foundation • 3835 N. Freeway Blvd, Suite 100, Sacramento, CA 95834 Teléfono ¿Qué son ¿Qué los nervios? Los nervios son una parte muy importante de su cuerpo. Lo ayudan a Si tiene diabetes, usted puede caminar y sentir dolor. oler, saborear, mantener sus nervios saludables con buen control de niveles A veces, la diabetes puede causar daño a los azúcar en la sangre. nervios. Esto puede ser muy doloroso. nervios a los daño de Señales El daño a los nervios puede ocurrir en partes diferentes en las manos y pies. Los del cuerpo. El más común ocurre médicos le llaman neuropatía diabética periférica (DPN). Si afirmativamente a cualquiera de estas preguntas, responde podría tener daños a los nervios debido la diabetes. Cabeza y ojos: • • Estómago e intestinos: • • Órganos sexuales: • Partes inferiores: • Manos y pies: •

124 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Toolkit No. 10 Protect Your Heart: Plan and Cook Heart-Healthy Meals

You can protect your heart and blood vessels by making smart choices when you cook. Small changes can make a big difference in your health. See the sections below for tips on how to • plan heart-healthy meals and snacks • cook heart-healthy meals Place a check mark next to 2 or 3 things you’re ready, willing, and able to try this week. Then use this list for more ideas later on.

For healthy recipes and food information, visit www.diabetes.org/MyFoodAdvisor. Plan heart-healthy meals and snacks Choose heart-healthy foods to protect your heart and Choose lean meat, poultry, and fish. blood vessels. J Check food labels and choose meats with 5 grams J of fat or less in each serving. Buy lower-fat cheeses: cottage cheese, grated Parmesan, and any cheese with 3 grams of fat or J Choose lean cuts of beef such as round, sirloin, and less per ounce. flank steak; tenderloin; rib, and rump roast; T-bone, porterhouse, and cubed steak. Choose whole-grain breads. J Pick lean types of pork: ham, Canadian bacon, J Check the list of ingredients on foods made from tenderloin, and rib and loin chops. grains. Choose foods that show “whole” or “whole J Buy sandwich meats with 3 grams of fat or less in grain” as the first ingredient. Whole-wheat flour, each ounce. whole oats, oatmeal, whole-grain cornmeal, J Other lean choices are leg of lamb, lamp chops, and popcorn, whole-rye flour, barley, and bulgur are all r TI P a roast lamb, and game, such as venison. whole grains. e s ou J Buy poultry such as chicken, turkey, and Cornish Make a whole-grain side dish several times a week. en rc t

hen without the skin (or remove the skin). J e Try whole-wheat pasta instead of regular pasta. s J Eat fish 2 or 3 times a week. Albacore tuna, herring, mackerel, rainbow trout, sardines, and salmon are J Have brown rice, whole-wheat couscous (a quick- great choices. cooking grain), or a boxed whole grain mix instead of white rice. Have a meatless meal at least once a week. Have plenty of fruits and vegetables. J Cook a vegetable pizza or lasagna. J Eat at least one vegetable or a salad at lunch and at J Try meatless chili dinner. J Make black bean soup or another hearty soup. J Eat dark green and dark yellow vegetables every J Stir-fry vegetables with tofu. day, such as broccoli, spinach, collards, kale, carrots, Choose fat-free or low-fat dairy foods. squash, and peppers. J 1 Snack on cut-up raw vegetables and fruit. J Choose fat-free (skim) milk, ⁄2% milk, or 1% milk. J Choose fruit for dessert—or when you’re craving J Use fat-free or low-fat yogurt. something sweet.

Puede proteger el corazón y los vasos sanguíneos tomando decisiones inteligentes cuando cocina. Los pequeños pasos pueden significar mucho para su salud. En las secciones a continuación encontrará consejos para: • planificar comidas y refrigerios sanos para el corazón • cocinar comidas sanas para el corazón Marque a continuación dos o tres pasos que esté listo y dispuesto a probar, y que pueda probar, esta semana. Use esta lista para más ideas más adelante.

Para recetas e información sobre los alimentos, visite www.portufamilia.org/miconsejerodecomida. Planifique comidas y meriendas sanas para el corazón Seleccione alimentos de forma inteligente para proteger el corazón y los vasos sanguíneos. Seleccione pescado y carne de res y aves magras. J Lea las etiquetas de los alimentos y seleccione carnes J con 5 gramos o menos de grasa en cada porción. Use yogur total o parcialmente descremado. J J Seleccione cortes de carne con menos grasa, tales Compre quesos con menos grasa: queso cottage y como bistec de bola, solomillo y bistec de costado; queso parmesano rallado; o cualquier queso con filete, costilla y asado de bola; T-bone, bistec del 3 gramos de grasa o menos por onza. costillar y bistec en cubos. Seleccione panes de cereales integrales o enteros. J Seleccione tipos magros de puerco: jamón, tocino J Lea la lista de ingredientes de los alimentos hechos canadiense, lomo, y chuletas de costilla y lomo. con cereales. Seleccione las que dicen “entero o J Compre carnes frías con 3 gramos o menos en cada integral” o “grano integral o entero” como primer onza. ingrediente. La harina de trigo integral, la avena J Otras opciones magras son: pierna y chuletas de entera, avena integral, el maíz entero, el grano de maíz cordero, asado de cordero y carnes de caza, como el para palomitas, la harina de centeno integral, la cebada venado. y el trigo bulgur son cereales integrales o enteros. J Compre aves tales como pollo, pavo y gallina de Haga un platillo con cereal integral varias veces por Cornualles, quíteles la piel o cómprelas sin piel. semana. J Coma pescado de dos a tres veces por semana. Estas J son buenas opciones: atún albacore, arenque Pruebe la pasta de trigo integral en lugar de la regular. macarela, trucha arcoiris, sardinas y salmón. J Coma arroz integral, cuscús de trigo integral (un grano de cocción rápida) o una mezcla de granos integrales Coma una comida sin carne por lo menos una vez por de caja en lugar de arroz blanco. semana. Coma muchos vegetales y frutas. J Cocine lasaña o pizza de vegetales. J J Pruebe el chili sin carne. Coma por lo menos un vegetal o una ensalada con el almuerzo y la cena. J Haga sopa de frijoles negros o de otros ingredientes J gustosos. Coma vegetales de color verde oscuro y amarillo todos los días. Por ejemplo: brócoli, espinaca, repollo, J Saltee las verduras con tofu. coliflor, zanahoria, calabaza, chiles y pimientos (ajíes). Seleccione alimentos lácteos sin grasa o de grasa J Coma vegetales crudas y fruta como merienda. reducida. J Coma fruta como postre o si tiene antojo de algo dulce. 1 J Seleccione leche descremada (sin grasa), o leche ⁄2 % ó 1%.

126 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Sources of Cholesterol and Fat Sources of Cholesterol and Fat Cholesterol Sat u rat e d / Trans Fat (Limit These) (Limit These) Unsaturated Fat

Meat Meat Cholesterol Sat u rat e d / Trans Fat Safflower oil (Limit CheeseThese) (LimitCheese These) Unsaturated Fat Sunflower oil Egg yolk Egg yolk Meat Meat Corn oil Whole milk Whole milk Safflower oil Polyunsaturated Cheese Cheese Soybean oil Reduced fat Reduced fat Sunflower oil Sesame oil Egg yolk(2%) milk Egg yolk(2%) milk Corn oil Ice cream Ice cream Walnuts Whole milk Whole milk Polyunsaturated SoybeanSesame oil seeds ReducedButter fat ReducedCream fat cheese Sesame oil (2%)Or milkgan meats (2%)Sour milk cream Walnuts Ice creamShellfish Ice crPalmeam oil Olive oil Sesame seeds Butter CreamCoconut cheese oil Canola oil Organ meats SourCocoa cream butter Peanut oil Shellfish PalmHydr oil ogenated or OliveOlives oil partially- Coconut oil hydrogenated CanolaAvocados oil Monounsaturated Vegetable oil (choose more .

Cocoa butter r TI P a PeanutAlmonds oil often) . e s ou HydrPoultryogenated with or en rc Peanuts t

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partially- e Cashews s hydrogenatedMargarine Avocados Monounsaturated Vegetable oil Pecans (choose more . Almonds often) . Poultry with Peanuts skin Cashews Margarine Pecans

Sources of Cholesterol & Fat Translation of this publication was supported by HRSA HCAP Grant # G92OA02204. ©2006 The Whittier Institute for Diabetes Permission granted by The Whittier Institute for Diabetes to copy for patient education purposes. For additional information see www.whittier.org

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 127 Sources of Cholesterol & Fat Translation of this publication was supported by HRSA HCAP Grant # G92OA02204. ©2006 The Whittier Institute for Diabetes Permission granted by The Whittier Institute for Diabetes to copy for patient education purposes. For additional information see www.whittier.org ConsejUnPalmaEjemplo:DedoPuñoConsejoVerSaturaConseConsejo el folleto de j#3#2o 1 puñadooz.pedazopulgar“ElInsatuColestPoliinsOtrasMonoiGrasa“Comiendo“Lea Alcoholde#1#4 la= de= 1 y lclaaerradoEtiqueta fueramanoDiabetes”de de de= qo1n zuesouecesó 2 oz. = de 1 s de oGrasasaturadnsaturda/TraEnseñanzsradaerol casa”Valorde botanaspuñado;31Nutricional” tazaoz. 2 Enseñansa (secasoz ada(noda“e)

Fuentes de Colesterol y Grasa

Colesterol Grasa Saturada/Trans Grasa Insaturada (Limite el consumo) (Limite el consumo)

Carne Carne Aceite de cártamo Queso Queso Aceite de girasol

Yema de huevo Yema de huevo Aceite de maíz Poliinsaturada Leche entera Leche entera Aceite de soya Leche descremada Leche descremada (2%) Aceite de ajonjolí (2%) Nieve o helado Nueces Nieve o helado Queso crema Ajonjolí Mantequilla Crema agria Vísceras Aceite de palmera Mariscos Aceite de coco Aceite de oliva Mantequilla de cacao Aceite de canola Aceite vegetal Aceite de hidrogenado o Cacahuate parcialmente Aceitunas Monoinsaturada hidrogenado Aguacates (elija más seguido) Carne de aves con piel Almendras Margarina Cacahuates Nueces de la India Nueces cáscara de papel

128 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Portion Sizes

Thumb = 1 Tablespoon or 1 oz. (liquid) Closed Fist = 1 Cup

Thumb Tip = 1 Teaspoon

Handful = 1 or 2 oz (dry) Snackfood r TI P a e s ou en rc t

e s Palm = 3 oz. 1 cooked serving of Chicken, Fish or Meat

Portion Sizes Translation of this publication was supported by HRSA HCAP Grant # G92OA02204. ©2006 The Whittier Institute for Diabetes Permission granted by The Whittier Institute for Diabetes to copy for patient education purposes. For additional information see www.whittier.org

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 129 ConsejConsejoVerConseConsejo el fofolletolleto j#3#2o “El“Comiendo“Lea Alcohol#1#4 la y laEtiqueta fueraDiabetes”de de de osEnseñan casa”Valorde z Nutricional” Enseñaa“

Tamaño de las Porciones

Ejemplo = 2 raciones de pasta Puño cerrado = 1 taza o avena

Palma de la mano = 3 oz. Ejemplo: 1 porción de carne cocinada

Punta del Pulgar = Ejemplo: 1 porción de 1 Cucharadita mayonesa o margarina

Ejemplo: 1 oz. de nueces = 1 Un puñado = 1 ó 2 oz. puñado; 2 oz. de pretzels = 2 de botanas (secas) puñados

Ejemplo: 1 pedazo de queso Dedo pulgar = 1 oz

130 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Toolkit No. 5 All About Physical Activity

What can physical activity do for me? Physical activity • helps keep your blood glucose (sugar), blood pressure, HDL cholesterol, and triglycerides on target • lowers your risk for pre-diabetes, type 2 diabetes, heart disease, and stroke • relieves stress • strengthens your heart, muscles, and bones • improves your blood circulation and tones your muscles • keeps your body and your joints flexible

Even if you’ve never exercised before, you can find ways to add physical activity to your day. You’ll get benefits, even if your activities aren’t strenuous. Once physical activity is a part of your routine, you’ll wonder how you did without it. Find an activity you enjoy, such as a dance aerobics class. If I haven’t been very active lately, what should I do first? J Play with the kids. J If you have health problems, start with a check up from Carry things upstairs in two trips instead of one. your health care provider. Your provider can recommend J Park at the far end of the shopping center lot and physical activities that will help you but won’t make your walk to the store. conditions worse. J Others things I can do: ______What kinds of physical activity are ______best? ______A complete physical activity routine includes 4 kinds of

activities: r TI P a e

Aerobic exercise s

1. activity—walking, using the stairs, moving around— ou en rc throughout the day Aerobic exercise makes your heart and bones strong, t

2. aerobic exercise, such as brisk walking, swimming, or relieves stress, and improves blood circulation. It also e dancing lowers your risk for type 2 diabetes, heart disease, and s 3. strength training, such as lifting light weights stroke by keeping your blood glucose, blood pressure, 4. flexibility exercises, such as stretching and cholesterol levels on target. Being active throughout the day Aim for about 30 minutes a day, at least 5 days a week. If you haven’t been very active recently, start out with 5 Being active helps burns calories. Place a check mark or 10 minutes a day. Then work up to more time each next to the things you’d like to try: week. Or split up your activity for the day—try a brisk J Walk instead of drive whenever possible. 10-minute walk 3 times each day. If you’re trying to lose J Take the stairs instead of the elevator. weight, you may want to aim for more than 30 minutes a J Walk around while you talk on the phone. day. J Work in the garden, rake leaves, or wash the car.

¿Qué beneficios tiene la actividad física? La actividad física: • lo ayuda a mantener los niveles deseados de glucosa (azúcar) en la sangre, y de presión arterial, colesterol HDL y triglicéridos • reduce su riesgo de contraer pre-diabetes, diabetes tipo 2, enfermedades del corazón y derrames cerebrales • alivia el estrés • fortalece el corazón y los músculos y huesos • mejora la circulación sanguínea y tonifica los músculos • mantiene flexibles el cuerpo y las articulaciones

Puede encontrar formas de aumentar su actividad física durante el día, aun si nunca ha hecho ejercicio. También se beneficiará aunque dicha actividad no sea muy agotadora. Una vez que la actividad física se convierta en parte de su rutina, se preguntará cómo Seleccione una actividad que disfrute como por ejemplo, una pudo vivir sin ella. clase de danza aeróbica.

No he estado muy activo recientemente, J Juegue con los niños ¿qué debo hacer primero? J Haga dos viajes en lugar de uno al subir las cosas por Si tiene problemas de salud, comience con una revisión las escaleras de parte de su proveedor de atención médica, quien le J Estacione el auto lejos de la tienda en el centro puede recomendar actividades físicas que lo ayudarán y comercial y camine hasta la tienda que no empeorarán sus padecimientos. J Otras cosas que puedo hacer: ¿Cuál es el mejor tipo de actividad física? ______Una rutina completa de actividad física incluye cuatro ______tipos de actividades: 1. caminar – activamente, subir las escaleras, ir de un ______lado a otro – durante el día 2. ejercicio aeróbico, tal como caminatas ágiles, nadar Ejercicio aeróbico o bailar El ejercicio aeróbico fortalece el corazón y los huesos, 3. fortalecimiento de los músculos tal como, alivia el estrés y mejora la circulación sanguínea. levantamiento de pesas livianas También reduce los riesgos de desarrollar diabetes tipo 2, 4. ejercicios de flexibilidad, tales como estiramientos enfermedades del corazón y derrames cerebrales, al mantener los niveles deseados de glucosa en la sangre, Actividad durante el día presión arterial y colesterol. Estar activo ayuda a quemar calorías. Marque a continuación las cosas que desear probar: Trate de caminar por lo menos treinta minutos diarios, J cinco días a la semana. Si no se ha mantenido muy activo Cuando le sea posible, camine en lugar de conducir recientemente, comience con cinco o diez minutos su auto diarios. Vaya añadiendo más tiempo cada semana. J Suba por las escaleras en lugar de tomar el ascensor También puede dividir su actividad del día: pruebe una J Camine mientras habla por teléfono caminata rápida de diez minutos, tres veces al día. Si está J Trabaje en el jardín, recoja hojas secas o lave su auto tratando de adelgazar, es aconsejable intentar caminar más de treinta minutos por día.

132 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 AND AND AND AND AND AND AND AND AND AND AND AND AND TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL activity activity activity activity activity activity activity activity moderate-intensity aerobic moderate-intensity aerobic Physical Activity PhysicalActivity Physical Activity PhysicalActivity Physical Activity PhysicalActivity u have to If you’re 2 days muscle strengthening strengthening muscle days 2 2 days muscle strengthening strengthening muscle days 2 2 days muscle strengthening strengthening muscle days 2 strengthening muscle days 2 2 days muscle strengthening strengthening muscle days 2 2 days muscle strengthening strengthening muscle days 2 75 minutes vigorous-intensity aerobic aerobic vigorous-intensity minutes 75 75 minutes vigorous-intensity aerobic aerobic vigorous-intensity minutes 75 30 minutes vigorous-intensity aerobic aerobic vigorous-intensity minutes 30 30 minutes vigorous-intensity aerobic aerobic vigorous-intensity minutes 30 90 minutes 90 minutes 150 minutes moderate-intensity aerobic 150 minutes moderate-intensity aerobic tennis Heavy of brisk walking Sunday Sunday Sunday Sunday Sunday Sunday gardening of doublesof 30 minutes minutes 45 Yoga band Weight training Saturday Saturday exercises Saturday gardening Resistance www.cdc.gov/physicalactivity Heavy tennis hiking of brisk walking of brisk walking of singles of jogging 25 minutes 25 minutes of vigorous 30 minutes 30 minutes 30 minutes oderate- or vigorous-intensity for at least 10 minutes at a time. for at least 10 minutes or vigorous-intensity oderate- lifting Weight Weight training of brisk walking the lawn Thursday Thursday Friday Thursday Thursday Friday Thursday Thursday Friday of mowing of mowing 30 minutes 30 minutes r TI P weekly activity routinesmay want you to try. a e For more information, see s Vigorous Aerobic Activity Routines Vigorous Aerobic Activity Moderate Aerobic Activity Routines Moderate Aerobic Activity ou en rc t

Yoga band of brisk walking e climbing of brisk walking of jogging of running s exercises 25 minutes 30 minutes 30 minutes Resistance Mix of Moderate and Vigorous Aerobic Activity Routines Mix of Moderate and Vigorous Aerobic Activity 25 minutes Rock lifting Weight softball of brisk Tuesday Wednesday walking Tuesday Wednesday of jogging Tuesday Wednesday 30 minutes of playing 30 minutes 60 minutes laps lifting tennis Weight of water Monday Monday Monday Monday aerobics of brisk walking walking of brisk of jogging Monday Monday of doublesof 25 minutes 25 minutes 30 minutes 45 minutes of swimming 30 minutes 30 minutes Example 3 Example 4 choose from. Basically anything counts, as long as it’s at a m as long from. Basically anything counts, choose of to start, here are some examples not sure where There are a lot of ways to get the physical you activity need! week?” each I meet the Guidelines can If you’re thinking, “How don’t worry. by the You’ll bevariety surprised of activities yo Example 5 Example 6 Example 1 Example 2

Many people with conditions like high blood pressure, high cholesterol or diabetes have a hard time taking their medicine the right way—or even taking it at all. Do you know the facts about taking your medicine? Here are some things you should know about prescription medicine. Myths You May Hear... The Facts Are... I don’t think I need • Feeling well does not mean your medical condition is cured. Many conditions—like medicine. I feel fine. high blood pressure, high cholesterol or diabetes—can damage your body, even if you I can take less or just do not have symptoms. stop taking it. • DO NOT stop or take less of a medicine for these conditions; this can be very dangerous. Talk to your health care provider first.

Generic medicine is • Generic medicine must pass the same quality tests as brand-name medicine. It is safe less expensive than and works just as well. brand-name medicine • Generic medicine is usually less expensive because many generic drug makers did not because it is not as good pay to develop the drug and do not pay for expensive advertising, so the savings are or as safe. passed on to you.

The only person I should Ask your pharmacist questions too! talk to about my medicine • Pharmacists are experts about medicine. They can help you to take your prescription is my doctor. correctly and deal with any side-effects. • Learn more about your medicine every time you pick up or drop off a prescription by talking to your pharmacist.

Medicine for conditions • Some medicine can cause sexual problems, but not treating your illness can cause like high blood pressure sexual problems as well as other health problems. or diabetes causes sexual • Discuss any side-effects you have—including sexual ones—with your doctor, nurse or problems. pharmacist. Often, they can adjust or change your medicine so you have fewer or no side-effects.

It’s safe to take home • Mixing prescription medicine with home remedies, non-prescription medicine, vitamins remedies, non-prescription and/or herbs at the same time can be dangerous! medicine, vitamins and/or • Tell your doctor or pharmacist about all remedies you use so that you are not risking herbs with my prescription your health. medicine.

If I take a medicine for • Medicine for chronic conditions like high blood pressure, high cholesterol or diabetes a long time, I will get is not addictive, even if you need to take it every day for many years. By taking these addicted to it. medicines every day, you can help prevent serious health problems like strokes, kidney failure or heart attacks.

It doesn’t matter • It does matter. You should fill all prescriptions at one pharmacy so your pharmacist how many different knows about all the medicine you are taking. That way, your pharmacist can help you pharmacies I use to take the right medicine and the right amount. get my prescriptions. • If you use one pharmacy, you can ask the pharmacist to get all your medicine on the same refill schedule, which will help you manage your medications. HPD1X25931 – 3.10 Take your medicine correctly. Your health—and your life—depend on it. For more information on taking your medicine, talk to your health care provider or pharmacist.

134 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 P1292–3.10 – HPD1X25932 ______Take My Medicine I Will Remember to Example: After I brush my teeth Date: ______Bedtime Name of Pharmacist: Phone Number: Evening . Talk to your health care provider or pharmacist right away. Noon When Do I Take It and How Much? Morning Example: 1 pill r TI P a e s ou en rc t

Name of Primary Care Provider: Phone Number: e s Is for This Medicine My______My Medication List – Keep It Handy Example: Hypertension (high blood pressure) of My Medicine Name and Dose Example: 25 mg Hydrochlorothiazide If you have any problems with your medicine – do not wait • List everything you take—prescriptions, over-the-counter• drugs, Bring vitamins, this herbs list and to supplements. every• doctor’s Don’t appointment, run if out you of go your to medicine—ask the your emergency doctor room for or a hospital, new and prescription when or you get go a to refill the from pharmacy. your pharmacist. Patient Name:

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 135 136 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

Practice/Clinic 7 Resources

CMAF DQIP Project California Diabetes Program Multicultural Patient Education Materials Database

Reducing Cardiometabolic Risk: Patient Education Toolkit (Preventive Cardiovascular Nurses Association, American Diabetes Association and the American College of Cardiology) Community Resource Directory Language Access Database Link to Informational Websites Billing and Coding Quick Reference Guide • ICD-9-CM Coding for Type 2 Diabetes Mellitus o ICD-9-CM Code Disease Diagnosis: Risk Factors o ICD-9-CM Coding for Type 2 Diabetes Mellitus o ICD-9-CM Code Disease Diagnosis: Complication and Co-morbidities • HCPCS Level II Codes for Self Monitoring Blood Glucose Products • HCPS Codes Medicare Preventive and Screening Services • Medicare Limitations pr fo Cl pr fo Cl i r ov

• HCPCS Codes Self-Management Training Services n i r ov

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CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 137 138 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

The Diabetes Quality Improvement Project is about doing the right thing for patients with diabetes at the point of care. It is about working as a team with members of the practice to ensure the best outcomes for patients with chronic disease. It is about utilizing appropriate technology to enhance what we do on a daily basis in solo and small practices. The Project is focused on improving the health of patients with diabetes and reducing the racial and ethnic health care disparities associated with this disease.

Project Goals: Improve the quality of care provided to diverse diabetes patient populations. Encourage medical offices to aggressively screen and identify patients at risk for diabetes. Effectively prevent and manage diabetes complications. Support team-based approaches to improve, track and monitor diabetes care. Share best practices associated with providing quality diabetes care. Provide multicultural community and patient education resources via the web.

Focus for 2011 & Beyond: Moving forward, the CMA Foundation will broaden its project focus. Areas of emphasis will include:

Implement health plan partnership to improve the quality of diabetes and cardiovascular health care throughout California

Spread of the Diabetes & Cardiovascular Disease Provider Reference Guide (PRG) nationally

Provider education programs (CME & non-CME)

Diabetes Quality Monograph for solo/small prac- r P ractic

For more information please contact Senely Navarrete, e

tice physicians s MPH, Project Director (916) 779-6638 or ou

[email protected]. rc

Team Care Toolkit for medical office staff e / e s CMA Foundation c Education materials on managing cardiovascular l i

3835 North Freeway Boulevard, Suite 100, Sacramento, CA 95834 n

risk, insulin therapy & medication management ic Phone: (916) 779-6620 • www.thecmafoundation.org

The Diabetes Quality Improvement Project is a project of the CMA Foundation.

2/7/11

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 139

CALIFORNIA DIABETES PROGRAM A CALIFORNIA DEPARTMENT OF PUBLIC HEALTH PROGRAM www.caldiabetes.org

The mission of the California Diabetes Program is to prevent diabetes and its complications in California’s diverse communities.

The California Diabetes Program was established in 1981, is part of the California Department of Public Health and is primarily funded by the Centers for Disease Control and Prevention (CDC).

The program works in partnership with organizations in California and nationwide to: • Conduct surveillance to monitor statewide diabetes health status and risk factors • Provide communications to increase awareness about diabetes • Guide public policy to support people with and at risk for diabetes • Offer leadership, guidance, and resources for community health interventions • Improve the quality of care in health care delivery systems • Reduce diabetes- related Health Disparities

As a coordinating leader for diabetes prevention and control, the California Diabetes Program is guided by national objectives and statewide goals, as well as community input. Our work ranges from supporting system-wide improvements in health care delivery systems to developing peer- to-peer education programs led by community volunteers. We promote proven methodologies including the Chronic Care Model and the team approach to care.

Brief success stories posted online describe some of our unique efforts to reduce diabetes risk factors, disability and death www.caldiabetes.org/content_display.cfm?ContentID=1117

California Diabetes Program Tools and Programs The California Diabetes Program has developed a variety tools and resources to aid health care providers in delivering quality diabetes care. The tools available to support patients, health care providers, community health workers, medical assistants, and diabetes health care providers, include:

• Basic guidelines for diabetes care packet – Developed in collaboration with the Diabetes Coalition of California, this evidence-based package provides easy to use tools for health care providers including user-friendly guidelines, patient flow sheet, and treatment algorithms.

• Diabetes health record card – Patient component of the basic guidelines. This tool is helpful for patient provide communication, tracking test dates, exam results, and health goals. Available online in 19 languages, printed copies in English and Spanish upon request via email: [email protected]

• Do you cAARd? Tobacco Cessation and Diabetes Online continuing Education Program – This no cost CEU provides key information about tobacco use and its effects on chronic disease, about cessation using the brief Ask Advise Refer cessation intervention, about quitline’s and pharmacotherapy. Visit www.caldiabetes.org to participate.

• Team Care – A resource compiled for health care professionals to assist in clinic systems

140 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 change provides tools and information to help increase quality care for diabetes. Find this resource at the Diabetes Information Resource Center atwww.caldiabetes.org

• California Diabetes Surveillance System – This system includes national and statewide survey data, vital statistics and hospital discharge data, health care system data, and local community data.

• Diabetes Information Resource Center (DIRC) – DIRC is a web-based portal containing diabetes information, resources, and data for use by organizations throughout California to contribute content and build a depository of information that is readily accessible to battle against diabetes. Visit this site to learn more about diabetes resources and to connect with partners.

For the most recent guidelines, please visit DIRC at www.caldiabetes.org

LEARN. DIRC includes best practices, data, health education tools and more.

SHARE. DIRC allows organizations to post a profile of their work and share their resources.

CONNECT. DIRC is a portal to find and connect with other diabetes organizations r P ractic e s ou rc e / e s c l i n ic

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 141

Multicultural Search by topic: Cardiovascular Disease and Diabetes Patient Education Complications / Miscellaneous Emotions Feelings Materials Exercise Eye Care Database Foot Care Medications Monitoring (Self-Management) A database of diabetes-related, Nutrition Prevention culturally and

linguistically appropriate Search by target audience: patient education Age and Gender materials available on our web site. Ethnicity and Race Materials in over 30 languages

Other features: Free and easy to use Download or print materials at no cost Search by materials format (i.e. coloring book or pamphlet) Author organization

TheThe Multicultural Multicultural Patient Patient Educational Educational Materials Database isis compiledcompiled withwith thethe assistanceassistance ofof anan expertexpert panel panel that that includes includes ethnic and regional physician organizations, community and ethnic and regional physician organizations, community and public health organizations. public health organizations.

To access the database and other diabetes-related resources, visit To access the database and other diabetes-related resources, visit the the project web site at http://www.thecmafoundation.org/ projectprojects/aped/. website at www.thecmafoundation.org > Diabetes Quality

For more information, please contact Senely Navarrete, MPH, For more information please contact Sandra Navarro, PhD, MPH, ProjectDirector Director of Clinical at (916)and Quality 779-6638 Improvement or by e-mail at at(916) 779-6637 or [email protected] e-mail at [email protected] .

CMA Foundation 3835 North Freeway Boulevard, Suite 100, Sacramento, CA 95834 Phone: (916) 779-6620 • www.thecmafoundation.org

Advancing Practice ExcellenceDiabetes Quality in Diabetes Improvement is a Quality Project Improvement of the CMA Initiative Foundation of the CMA Foundation.

4/09 142 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Reducing Cardiometabolic Risk: Patient Education Toolkit This toolkit contains 29 patient education handouts on topics related to diabetes and cardiovascular disease. All handouts are freely reproducible, no-cost and available in English and Spanish. The toolkit was developed by the American Diabetes Association, the American College of Cardiology and the Preventive Cardiovascular Nurses Association. http://www.pcna.net/clinical/diabetes/index.php You may request a no-cost CD-ROM of all handouts by emailing the American Diabetes Association at [email protected].

Sample Topics in the Reducing Cardiometabolic Risk: Patient Education Toolkit

In English En Espanol 1. All About Pre-Diabetes 1. Todo sobre la prediabetes 2. Getting the Very Best Care for Your Diabetes 2. Cómo obtener el mejor cuidado para su diabetes 3. Taking Care of Type 2 Diabetes 3. Cómo cuidar la diabetes tipo 2 4. All About Your Blood Glucose for People 4. Todo sobre la glucosa en la sangre para with Type 2 Diabetes personas con diabetes tipo 2 5. All About Insulin Resistance 5. Todo sobre la resistencia a la insulina 6. Protect Your Heart: Make Wise Food 6. Proteja su corazón: Seleccione sus Choices alimentos con cuidado 7. Protect Your Heart: Choose Fats Wisely 7. Proteja su corazón: Seleccione las grasas con cuidado 8. Protect Your Heart: Cook with Heart Healthy 8. Proteja su corazón: Cocine con alimentos Foods saludables para el corazón 9. Protect your Heart: Check Food Labels to 9. Proteja su corazón: Lea las etiquetas de Make Heart-Healthy Choices los alimentos para seleccionar los que son saludables para el corazón 10. All About Carbohydrate Counting 10. Todo sobre el conteo de los carbohidratos 11. Protect Your Heart by Losing Weight 11. Proteja su corazón bajando de peso 12. All About Physical Activity for People with 12. Todo sobre como ser activo físicamente

Diabetes cuando se tiene diabetes r P ractic e s 13. Getting Started with Physical Activity 13. Cómo empezar a ser activo ísicamente ou rc e /

14. Learning How to Change Habits 14. Aprenda a cambiar sus hábitos e s c l i

15. Recognizing and Handling Depression for 15. Cómo reconocer y manejar la depresión n People with Diabetes cuando se tiene diabetes ic 16. Treating High Blood Pressure in People with 16. Sobre el tratamiento de la presión alta de la Diabetes sangre cuando se tiene diabetes 17. Treating High Cholesterol in People with 17. Sobre el tratamiento para el colesterol alto Diabetes cuando se tiene diabetes 18. Taking Care of Your Heart 18. Cómo cuidar su corazón

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 143 In addition to the Reducing Cardiometabolic Risk: Patient Education Toolkit, the Preventive Cardiovascular Nurses Association offers the following patient education resources. All resources are downloadable and may also be ordered free of charge.

Reducing Cardiometabolic Risk: Patient Education Toolkit: This comprehensive toolkit, developed by PCNA, the American Diabetes Association, and the American College of Cardiology, contains printable patient education materials related to diabetic cardiovascular care. There are more than 25 topic areas covering everything from Type 2 diabetes and glucose control to vascular disease. Also included are forms for tracking key goals and logging daily eating and physical activity patterns. This tool kit is available on CD.

Antiplatelet Therapy: This free patient education handout provides an overview of the important role of platelets in the development of acute coronary syndrome, heart attack, and stroke. It reviews basic information on antiplatelet medications and indications for use. Also included are important instructions for taking antiplatelet medications. These include a chart to track dosing, what to expect when taking these medicines, and tips on how to incorporate a heart healthy diet and exercise into the daily routine. (©2010)

Hypertension: Patient Education “How do you measure up?” patient booklet was developed by PCNA to educate patients at risk for CVD due to hypertension. This booklet provides information on home blood pressure monitoring, exercise and nutrition, behavior change and medication therapies. This booklet will also help your patients understand if they have normal, are at risk for, or have high blood pressure and what they can do to achieve normal blood pressure. (©2010)

Triglycerides and HDL: Patient Education This free educational handout for patients outlines risk reduction strategies and explains how to lower triglycerides and raise HDL through healthy eating and exercise. Easy to read tables provide examples of heart healthy activities for adults as well as common medications used to lower triglycerides and raise HDL-cholesterol. (©2010)

Angina: Patient Education The Get Tough on Angina™ patient education materials were designed for health care providers to use when educating their patients and the family and friends of patients about angina. The Get Tough on Angina patient booklet is the most comprehensive educational resource currently available to patients with angina. The patient brochure, available in English and Spanish, provides quick information on angina including how to reduce attacks and how to cope with symptoms. (©2010)

144 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Community Resource Directory The Community Resource Directory is a collaboration between the California Medical Association Foundation and the Network for a Healthy California to identify programs and resources for individuals at risk for overweight, obesity and type 2 diabetes.The directory contains resources for all counties in the state, with extensive resources in the North Coast, Central Valley, Gold Country, Central Coast, and Desert Sierra regions.

Programs and resources in the directory include:

• Behavioral/mental health: Group support, private counseling and 24-hour crisis hot lines

• Child health: Programs and activities for children, as well as advocacy groups for child health and safety

• Clinics: Medical clinics providing care and education specifically tailored for patients with diabetes

• Diabetes counseling & education: One-on-one or small group education and support for individuals with diabetes

• Education materials: Health education resources on nutrition and healthy eating, physical activity, overweight/obesity and diabetes

• Environmental health: Advocacy groups on clean and green environments

• Family relation building: Programs and activities for the whole family, as well as counseling and support for troubled families

• Health services for low-income: Information on Medicaid and other low cost health service options

• Food resources: Supplemental food or food vouchers such as food stamps and WIC, as well as information and locations for Famers’ markets, food banks, and congregate meal facilities

• Nutrition education: Community education programs addressing healthy eating r P ractic e

s • Physical activity: Low cost or free exercise classes and sports teams ou rc e /

e s c

• State and national parks: Recreation areas and parks with hiking and biking trails as well as other l i n

facilities for physical activities ic

To access the community resource directory, visit http://www.thecmafoundation.org/applications/ ProgramSearchHome.aspx

The Medical Leadership Council (MLC) Language Access Database provides a wealth of local, state, and national resources to assist physicians, other health care providers, and their staff in providing language access and culturally proficient health care for patients. The database is searchable by California county, by specific language, and by resource type. Users can search by any of these categories or by a combination of two or three.

The database can be accessed at this website: http://www.medicalleadership.org/resources/database.shtml.

Resources include interpreter contact information, patient education materials in a variety of languages, and local and national organizations providing services in languages other than English.

The listings included are not exhaustive, and are not endorsed or guaranteed by The California Endowment, the California Academy of Family Physicians, or the Medical Leadership Council on Cultural Proficiency. MLC member organizations are continually researching local resources and adding to this database, so please check back regularly. To comment on any listed resources please email [email protected].

146 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Link to Informational Websites

American Academy of Ophthalmology Division of Diabetes Translation http://www.aao.org/ 877-232-3422 http://www.cdc.gov/diabetes American Academy of Optometry http://www.aaopt.org Centers for Medicare & Medicaid Services http://www.cms.gov American Academy of Periodontology http://www.perio.org Indian Health Services Diabetes Program www.ihs.gov/MedicalPrograms/Diabetes/ American Association of Clinical index.asp Endocrinologists (AACE) http://www.aace.com Learning About Diabetes http://www.learningaboutdiabetes.org/ American Association of Diabetes Educators (AADE) - 800-TEAM-UP4 National Association of Chain Drug Stores http://www.aadenet.org http://www.nacds.org American College of Clinical Pharmacy National Community Pharmacists Association http://www.accp.com http://www.ncpanet.org American Dental Association National Diabetes Education Program http://www.ada.org http://www.ndep.nih.gov http://www.betterdiabetescare.nih.gov American Dental Hygienists Association 800-243-ADHA National Diabetes Information Clearinghouse http://www.adha.org/ 800-860-8747 http://diabetes.niddk.nih.gov American Diabetes Association (ADA) 800-342-2383 National Eye Institute http://www.diabetes.org 301-496-5248 http://www.nei.nih.gov American Dietetic Association 800-366-1655 National Heart, Lung, and Blood Institute http://www.eatright.org http://www.nhlbi.nih.gov American Optometric Association National Institute of Diabetes, Digestive and http://www.aoa.org Kidney Diseases http://www.niddk.nih.gov American Pharmacists Association http://www.aphanet.org National Optometric Association http://www.natoptassoc.o American Podiatric Medical Association http://www.apma.org

American Public Health Association r P ractic e

http://www.apha.org s ou

American Society of Health-System Pharmacists rc e / e

http://www.ashp.org s c l i n

California Diabetes Program ic http://www.caldiabetes.org

Centers for Disease Control and Prevention

ICD9-CM Coding for Type 2 Diabetes Mellitus71 The International Classification of Diseases, 9th Revision, Clinical Modification, also known as ICD-9-CM, is the official United States system of assigning codes to medical diagnoses. The following two tables list ICD-9-CM diagnoses and codes for diabetes risk factors and cardiovascular comorbidities, and for type 2 diabetes mellitus

Table 41: ICD 9-CM Coding for Diabetes Risk Factors and Cardiovascular Comorbid Diagnoses

Diagnosis ICD-9-CM code Impaired fasting glucose 790.21 Elevated fasting glucose Impaired glucose tolerance test (oral) 790.22 Elevated glucose tolerance test Other abnormal glucose 790.29 Abnormal glucose, non specific (NOS) Abnormal non-fasting glucose Hyperglycemia (NOS) Pre-diabetes (NOS) Dysmetabolic syndrome X 277.7 Use Additional Code: for associated manifestation, such as: cardiovascular disease (414.00-414.07) obesity (278.00-278.03) Hypertensive disease Essential hypertension: Malignant 401.1 Benign 401.2 Unspecified 401.9

Hypertensive heart disease: Malignant – Without heart failure 402.00 Malignant – With heart failure 402.01 Benign – Without heart failure 402.10 Benign – With heart failure 402.11 Unspecified – Without heart failure 402.90 Unspecified – With heart failure 402.91

148 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 41: ICD 9-CM Coding for Diabetes Risk Factors and Cardiovascular Comorbid Diagnoses Hypertensive chronic kidney disease Malignant, with chronic kidney disease stage I through stage 403.00 IV, or unspecified Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9)

Malignant, with chronic kidney disease stage V or end stage 403.01 renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Diagnosis ICD-9-CM code Benign, with chronic kidney disease stage I through stage IV, 403.10 or unspecified Impaired fasting glucose 790.21 Use Additional Code: to identify the stage of chronic kidney disease Elevated fasting glucose (585.1-585.4, 585.9) Impaired glucose tolerance test (oral) 790.22 Benign, with chronic kidney disease stage V or end stage 403.11 Elevated glucose tolerance test renal disease Other abnormal glucose 790.29 Use Additional Code: to identify the stage of chronic kidney disease Abnormal glucose, non specific (NOS) (585.5, 585.6) Abnormal non-fasting glucose Unspecified, with chronic kidney disease stage I through 403.90 Hyperglycemia (NOS) stage IV, or unspecified Pre-diabetes (NOS) Use Additional Code: to identify the stage of chronic kidney disease Dysmetabolic syndrome X 277.7 (585.1-585.4, 585.9) Use Additional Code: for associated Unspecified, with chronic kidney disease stage V or end stage 403.91 manifestation, such as: renal disease cardiovascular disease (414.00-414.07) Use Additional Code: to identify the stage of chronic kidney disease obesity (278.00-278.03) (585.5, 585.6) Hypertensive disease Hypertensive heart and chronic kidney disease Essential hypertension: Malignant 401.1 Malignant, without heart failure and with chronic kidney 404.00 Benign 401.2 disease stage I through stage IV, or unspecified Unspecified 401.9 Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9) Hypertensive heart disease: Malignant – Without heart failure 402.00 Malignant, with heart failure and with chronic kidney disease 404.01

stage I through stage IV, or unspecified r P ractic Malignant – With heart failure 402.01 e s

Benign – Without heart failure 402.10 Use Additional Code: to identify the stage of chronic kidney disease ou

Benign – With heart failure 402.11 (585.1-585.4, 585.9) rc e / e s

Unspecified – Without heart failure 402.90 Malignant, without heart failure and with chronic kidney 404.02 c l i Unspecified – With heart failure 402.91 disease stage V or end stage renal disease n ic Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Malignant, with heart failure and chronic kidney disease stage 404.03 V or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5-585.6)

Benign, without heart failure and with chronic kidney disease 404.10 stage I through stage IV, or unspecified Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9) Benign, with heart failure and with chronic kidney disease 404.11 stage I through stage IV, or unspecified Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9) Benign, without heart failure and with chronic kidney disease 404.12 stage V or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Benign, with heart failure and chronic kidney disease stage V 404.13 or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5-585.6) Unspecified, without heart failure and with chronic kidney 404.90 disease stage I through stage IV, or unspecified Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9) Unspecified, with heart failure and with chronic kidney 404.91 disease stage I through stage IV, or unspecified Use Additional Code: to identify the stage of chronic kidney disease (585.1-585.4, 585.9) Unspecified, without heart failure and with chronic kidney 404.92 disease stage V or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Unspecified, with heart failure and chronic kidney disease 404.93 stage V or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5-585.6) Secondary hypertension

Malignant – Renovascular 405.01 Malignant – Other 405.09 Benign – Renovascular 405.11 Benign – Other 405.19 Unspecified – Renovascular 405.91 Unspecified - Other 405.99

150 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 41: ICD 9-CM Coding for Diabetes Risk Factors and Cardiovascular Comorbid Diagnoses

Dyslipidemia Pure hypercholesterolemia 272.0 Familial hypercholesterolemia Fredrickson Type IIa hyperlipoproteinemia Hyperbetalipoproteinemia Hyperlipidemia, Group A Low-density-lipoid-type [LDL] hyperlipoproteinemia Pure hyperglyceridemia 272.1 Endogenous hyperglyceridemia Fredrickson Type IV hyperlipoproteinemia Hyperlipidemia, Group B Hyperprebetalipoproteinemia Hypertriglyceridemia, essential Very-low-density-lipoid-type [VLDL] hyperlipoproteinemia Mixed hyperlipidemia 272.2 Broad- or floating-betalipoproteinemia Combined hyperlipidemia Elevated cholesterol with elevated triglycerides NEC Fredrickson Type IIb or III hyperlipoproteinemia Hypercholesterolemia with endogenous hyperglyceridemia Hyperbetalipoproteinemia with prebetalipoproteinemia Tubo-eruptive xanthoma Xanthoma tuberosum Hyperchylomicronemia 272.3 Burger-Grutz syndrome Fredrickson type I or V hyperlipoproteinemia Hyperlipidemia, Group D Mixed hyperglyceridemia Other and unspecified hyperlipidemia 272.4 Alpha-lipoproteinemia Hyperlipidemia NOS Hyperlipoproteinemia NOS

Overweight and obesity r P ractic e s Obesity 278.00 ou rc e /

(use additional code to identify body mass index, if know e s c

(V85.0-V85.54) l i n Morbid obesity 278.01 ic (increased weight beyond limits of skeletal and physical requirements (125 percent or more over ideal body weight) as a result of excess fat in subcutaneous connective tissues (BMI greater than 39)

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 151 Table 42: ICD 9-CM Coding for Type 2 Diabetes Mellitus Diagnoses ICD- 9-CM Diagnosis Code Diabetes mellitus type 2 Diabetes mellitus: codes under category 250, diabetes mellitus, identify complications/ manifestations associated with diabetes mellitus. A fifth-digit is required for all category 250 codes to identify the type of diabetes mellitus and whether the diabetes is controlled or uncontrolled.

Diabetes mellitus  Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.00 o Fifth digit “0” is for use for type II patients even if the patient requires insulin  Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.02 o Fifth digit 2 is for use for type II patients even if the patient requires insulin Diabetes with ketoacidosis  Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.10 o Fifth digit 0 is for use for type II patients even if the patient requires insulin  Diabetes with ketoacidosis, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.12 o Fifth digit 2 is for use for type II patients even if the patient requires insulin

Diabetes with hyperosmolarity  Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.20 o Fifth digit 0 is for use for type II patients even if the patient requires insulin  Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.22 o Fifth digit 2 is for use for type II patients even if the patient requires insulin

152 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 42: ICD 9-CM Coding for Type 2 Diabetes Mellitus Diagnoses ICD- 9-CM Diagnosis Code Diabetic Coma o Diabetic coma (with ketoacidosis) o Diabetic hypoglycemic coma o Insulin coma NOS Excludes: diabetes with hyperosmolar coma (250.2)  Diabetes with other coma, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.30 o Fifth digit 0 is for use for type II patients even if the patient requires insulin

 Diabetes with other coma, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.32 o Fifth digit 2 is for use for type II patients even if the patient requires insulin Diabetes with renal manifestations:  Use Additional Code: to identify manifestation, as: -chronic kidney disease (585.1-585.9) -diabetic: nephropathy NOS (583.81) nephrosis (581.81) -intercapillary glomerulosclerosis (581.81) -Kimmelstiel-Wilson syndrome (581.81)

 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.40 o Fifth digit 0 is for use for type II patients even if the patient requires insulin  Diabetes with renal manifestations, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 o Fifth digit 2 is for use for type II patients even if the patient requires 250.42 r P ractic insulin e s ou rc

Diabetes with ophthalmic manifestations e / e s Use Additional Code: to identify manifestation, as: c

o l i diabetic: n blindness (369.00-369.9) ic cataract (366.41) 250.50 glaucoma (365.44) macular edema (362.07) retinal edema (362.07) retinopathy (362.01-362.07)

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 153 Table 42: ICD 9-CM Coding for Type 2 Diabetes Mellitus Diagnoses ICD- 9-CM Diagnosis Code  Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled Use Additional Code: if applicable, for associated long-term (current) insulin use V58.67 Fifth digit 2 is for use for type II patients even if the patient requires 250.52 insulin

Diabetes with neurological manifestations  Use Additional Code: to identify manifestation, as: diabetic: amyotrophy (353.5) gastroparalysis (536.3) gastroparesis (536.3) mononeuropathy (354.0-355.9) neurogenic arthropathy (713.5) peripheral autonomic neuropathy (337.1) polyneuropathy (357.2)  Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.60  Fifth digit 0 is for use for type II patients even if the patient requires insulin

 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 o Fifth digit 2 is for use for type II patients even if the patient requires 250.62 insulin

Diabetes with peripheral circulatory disorders  Use Additional Code: to identify manifestation, as: diabetic: gangrene (785.4) peripheral angiopathy (443.81)  Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.70 o Fifth digit 0 is for use for type II patients even if the patient requires insulin

 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 o Fifth digit 2 is for use for type II patients even if the patient requires 250.72 insulin

154 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 42: ICD 9-CM Coding for Type 2 Diabetes Mellitus Diagnoses ICD- 9-CM Diagnosis Code Diabetes with other specified manifestations o Diabetic hypoglycemia NOS o Hypoglycemic shock NOS o Use Additional Code: to identify manifestation, as: any associated ulceration (707.10-707.9) diabetic bone changes (731.8)  Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.80 o Fifth digit 0 is for use for type II patients even if the patient requires insulin  Diabetes with other specified manifestations, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.82 o Fifth digit 2 is for use for type II patients even if the patient requires insulin

Diabetes with unspecified complication  Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.90 o Fifth digit 0 is for use for type II patients even if the patient requires insulin  Diabetes with unspecified complication, type II or unspecified type, uncontrolled o Use Additional Code: if applicable, for associated long term (current) insulin use V58.67 250.92 o Fifth digit 2 is for use for type II patients even if the patient requires insulin Other disorders of pancreatic internal secretion  Hypoglycemic coma 251.0  Other specified hypoglycemia 251.1  Hypoglycemia, unspecified 251.2 r P ractic  e Post surgical hypoinsulinemia 251.3 s  Abnormal secretion of glucagon 251.4 ou rc

 e / Abnormal secretion of gastrin 251.5 e s  c Other specified disorder of pancreatic internal secretion 251.8 l i  n Unspecified disorder of pancreatic internal secretion 251.9 ic E xclusions  Diabetes, complications associated with pregnancy, childbirth, or the 648.8 peurperium  Gestation diabetes, abnormal glucose tolerance 790.2  Non clinical diabetes 648.0

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 155 Table 43: ICD 9-CM Coding for Diabetes Related Complications and/or Comorbidities Diagnosis ICD-9-CM code Cardiovascular disease  Hyperchylomicronemia 272.3  Other and unspecified hyperlipidemia 272.4  Acute myocardial infarction (4th digit required) 410.0  Other acute and subacute forms of ischemic heart disease (4th digit required) 411.0  Old myocardial infarction 412.0  Angina pectoris (4th digit required) 413.0  Coronary atherosclerosis (5th digit required) 414.0  Cardiovascular disease, unspecified 429.2  Occlusion of cerebral arteries (4th digit required) 434.0  Transient cerebral ischemia (4th digit required) 435.0  Other and unspecified cerebrovascular disease (4th digit required) 437.0 Diabetic retinopathy Code First: diabetes (249.5, 250.5)  Background diabetic retinopathy o Diabetic retinal microaneurysms 362.01 o Diabetic retinopathy NOS  Proliferative diabetic retinopathy 362.02  Nonproliferative diabetic retinopathy, NOS 362.03  Mild nonproliferative diabetic retinopathy 362.04  Moderate nonproliferative diabetic retinopathy 362.05  Severe nonproliferative diabetic retinopathy 362.06  Diabetic macular edema o Diabetic retinal edema Note: Code 362.07 must be used with a code for diabetic 362.07 retinopathy (362.01-362.06)  Glaucoma 365.9  Diabetic cataract 366.41 o Code First: diabetes (249.5, 250.5) Other complications  Polyneuropathy in diabetes 357.2 o Code First: underlying disease (249.6, 250.6)  Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere 583.81 o Code First: underlying disease, as: diabetes mellitus (249.4, 250.4)  Acquired acanthosis nigricans 701.2 o Keratosis nigricans (…often associated with diabetes)  Proteinuria (albuminuria) 791.0

156 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011

HCPCS Level II Codes for Self Monitoring Blood Glucose Products Level II HCPCS codes are used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as durable medical equipment which includes blood glucose monitors and supplies used by patients outside a physician’s office, including:

Table 44: HCPCS Codes Self Monitoring Blood Glucose Products

Description HCPCS code Blood glucose test or reagent strips for home blood glucose monitor per 50 strips A4253 Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by each A4233 patient Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient each A4234

Normal, low and high calibrator solution / chips A4256

Spring-powered device for lancet each A4258 Lancets per box (100) A4259

Home blood glucose monitor E0607

Blood glucose monitor with integrated voice synthesizer E2100

Platforms for home blood glucose monitor 50 per box A4255

^ Typically not covered: A4250 Urine test or reagent strips/tablets r P ractic e s ou rc e / e s c l i n ic

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 157 HCPCS Codes Medicare Preventive and Screening Services The following tables contain commonly used procedure codes for diabetes related prevention and screening services, including Medical Nutrition Therapy (MNT) and Diabetes Self Management Trainings (DSMT).

Table 45: HCPCS Codes Medicare Preventive and Screening Services

Service Description Procedure code Covered diagnosis Influenza Vaccine

Influenza virus vaccine, split virus, preservative free, 90655 V04.81 when administered to children 6-35 months of age, for intramuscular use Note: Providers must report diagnosis code Influenza virus vaccine, split virus, preservative free, 90656 V06.6 on claims when when administered to individuals 3 years and older, for the purpose of the visit intramuscular use was to receive both the pneumococcal Influenza virus vaccine, spilt virus, when administered to 90657 and influenza vaccines children 6-35 months of age, for intramuscular use during the same visit.

Influenza virus vaccine, split virus, when administered 90658 to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, live, for intranasal use 90660 Influenza virus vaccine, split virus, preservative free, 90662 enhanced immunogenicity via increased antigen content, for intramuscular use

Influenza Administration

Immunization administration through 18 years of age 90460 via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration (includes percutaneous, 90471 intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; 90473 1 vaccine (single or combination vaccine/toxoid) When billing Medicare, use HCPCS code for G0008 administration of influenza vaccine

158 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 45: HCPCS Codes Medicare Preventive and Screening Services

Service Description Procedure code Covered diagnosis

Pneumococcal vaccine

Pneumococcal conjugate vaccine, polyvalent, for 90669 V03.82 children under 5 years, for intramuscular use Note: Providers must Pneumococcal conjugate vaccine, polyvalent, for 90669 report diagnosis code children under 5 years, for intramuscular use V06.6 on claims when Pneumococcal conjugate vaccine, 13-valent, for 90670 the purpose of the intramuscular use visit was to receive Pneumococcal polysaccharide vaccine, 23-valent, 90732 both pneumococcal adult or immunosuppressed patient dosage, for use and influenza vaccines in individuals 2 years or older, for subcutaneous or during the same visit. intramuscular use To bill Medicare, report both vaccine codes and Pneumococcal Administration administration codes on the same claim form When billing Medicare, use HCPCS code for G0009 or electronic format. administration of pneumococcal vaccine HINI Vaccine

Influenza virus vaccine, pandemic formulation, H1N1 90663 V04.81 Level II Healthcare Common Procedure Coding System G9142 code is used to identify the H1N1 vaccine on Medicare claims Glaucoma Screening G0117 V80.1 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist (every 12 months) Glaucoma screening for high risk patient furnished G0118 under the direct supervision of an optometrist or ophthalmologist

r P ractic Glucose e s ou rc

Glucose; quantitative, blood (except reagent strip) 82947 V77.1 e / e s c

post glucose dose (includes glucose) 82950 l i n tolerance test (GTT), three (3) specimens (includes 82951 ic glucose)

Service Description Procedure code Covered diagnosis

Lipid panel

This panel must include the following: 80061 One or more of the Cholesterol, serum, total (82465) following: V81.0, V81.1, Lipoprotein, direct measurement, high density V81.2 cholesterol (HDL cholesterol) (83718) Triglycerides (84478) *See excerpt of 190.23 Lipids Testing Medicare National Coverage Determination below

Cholesterol (Every 5 years for asymptomatic 82465 One or more of the beneficiaries) following: V81.0, V81.1, V81.2

Lipoprotein (Every 5 years for asymptomatic 83718 One or more of the beneficiaries) following: V81.0, V81.1, V81.2

Triglycerides (Every 5 years for asymptomatic 84478 One or more of the beneficiaries) following: V81.0, V81.1, V81.2

* 190.23 Lipids Testing http://www.cms.gov/CoverageGenInfo/Downloads/manual201104.pdf

160 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Description Lipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. These lipoproteins include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and E apoproteins. Total cholesterol comprises all the cholesterol found in various lipoproteins.

Factors that affect blood cholesterol levels include age, sex, body weight, diet, alcohol and tobacco use, exercise, genetic factors, family history, medications, menopausal status, the use of hormone replacement therapy, and chronic disorders such as hypothyroidism, obstructive liver disease, pancreatic disease (including diabetes), and kidney disease.

In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Blood levels of the above cholesterol components including triglyceride have been separated into desirable, borderline and high-risk categories by the National Heart, Lung, and Blood Institute in their report in 1993. These categories form a useful basis for evaluation and treatment of patients with hyperlipidemia. Therapy to reduce these risk parameters includes diet, exercise and medication, and fat weight loss, which is particularly powerful when combined with diet and exercise.

Indications The medical community recognizes lipid testing as appropriate for evaluating atherosclerotic cardiovascular disease. Conditions in which lipid testing may be indicated include: • Assessment of patients with atherosclerotic cardiovascular disease • Evaluation of primary dyslipidemia • Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease • Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism • Secondary dyslipidemia, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure • Signs or symptoms of dyslipidemias, such as skin lesions • As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol)

when total cholesterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/ r P ractic e s

dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol <35 mg/dL ou rc e / e s Medicare Limitations c l i n Lipid panel and hepatic panel testing may be used for patients with severe psoriasis which has not ic responded to conventional therapy and for which the retinoid etretinate has been prescribed and who have developed hyperlipidemia or hepatic toxicity. Specific examples include erythrodermia and generalized pustular type and psoriasis associated with arthritis. Routine screening and prophylactic testing for lipid disorder are not covered by Medicare. While lipid screening may be

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 161 medically appropriate, Medicare by statute does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use, etc.

Once a diagnosis is established, one or several specific tests are usually adequate for monitoring the course of the disease. Less specific diagnoses (for example, other chest pain) alone do not support medical necessity of these tests.

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

If no dietary or pharmacological therapy is advised, monitoring is not necessary. When evaluating non-specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more than twice per year

Table 46: HCPCS Codes Self-Management Training Services

Diabetes self-management training services

Diabetes outpatient self-management training Individual per 30 minutes G0108 services

Diabetes outpatient self-management training Group session(2 or per 30 minutes G0109 services more individuals)

162 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 47: CPT Codes Medical Nutrition Therapy (MNT)

Diagnosis Code  Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes 97802  Medical Nutrition Therapy; re-assessment and intervention, individual, face-to-face with the patient each 15 minutes 97803  Medical Nutrition Therapy; group (2 or more), face-to-face with patient, each 30 minutes 97804

*Medicare MNT Code  Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face G0270 with the patient, each 15 minutes o Requires referral for beneficiaries with diabetes or renal disease o Services must be provided by a dietitian or nutritionist *Medicare MNT Code  Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more G0271 individuals), each 30 minutes o Requires referral for beneficiaries with diabetes or renal disease o Services must be provided by a dietitian or nutritionist

* For Medicare-covered MNT services, CMS established two HCPCS level II G-codes (see codes above) for MNT reassessment and subsequent intervention following a second referral in the same calendar year for a change in diagnosis, medical condition, or treatment regimen. G codes are used to identify professional health care procedures and services for which there are no specific CPT codes. According to a Medicare Intermediary Program Memorandum (Transmittal A-02-115), dated November 1, 2002, “These new G-codes should be used when additional hours of MNT services are performed beyond the number of hours typically covered (3 hours in the initial calendar year, and 2 follow-up hours in subsequent years with a physician referral) when the treating physician determines there is a change of diagnosis or medical condition that makes a change in diet necessary.” Non-Medicare third-party payers may prefer, that RDs and other licensed nutrition professionals report MNT reassessment and subsequent intervention in the

same calendar year using MNT CPT codes 97803 and 97804 for individual and group follow-up MNT encounters, respectively. For r P ractic e reporting these MNT services for non-Medicare patients, check third-party payers’ policies and guidelines. s ou rc e / e s c l i n ic

Diagnosis ICD-9-CM code Organ or tissue replaced by transplant; kidney V42.0

Diabetes mellitus 250.00 - 250.93 Hypertensive chronic kidney disease: Malignant, with chronic kidney disease stage V or end stage renal 403.01 disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Benign, with chronic kidney disease stage V or end stage renal disease 403.11 Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Unspecified, with chronic kidney disease stage V or end stage renal 403.91 disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6)

Hypertensive heart: Malignant, without heart failure and with chronic kidney disease stage V 404.02 or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Malignant, with heart failure and chronic kidney disease stage V or end 404.03 stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Benign, without heart failure and with chronic kidney disease stage V or 40.12 end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Benign, with heart failure and chronic kidney disease stage V or end 404.13 stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Unspecified, without heart failure and with chronic kidney disease stage 404.92 V or end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6)

164 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table 48: ICD-9-CM Codes that Support Medical Nutrition Therapy (MNT) Services

Unspecified, with heart failure and chronic kidney disease stage V or 404.93 end stage renal disease Use Additional Code: to identify the stage of chronic kidney disease (585.5, 585.6) Chronic kidney disease (Stages 1 through V) 585.1 - 585.5 End stage renal disease 585.6 Chronic kidney disease requiring chronic dialysis Chronic kidney disease, unspecified 585.9 Chronic renal disease Chronic renal failure NOS Chronic renal insufficiency Unspecified disorder of kidney and ureter 593.9 Acute renal disease Acute renal insufficiency Renal disease NOS Salt-losing nephritis or syndrome Excludes: chronic renal insufficiency (585.9) cystic kidney disease (753.1) nephropathy, so stated (583.0-583.9) renal disease: arising in pregnancy or the puerperium (642.1-642.2, 642.4-642.7, 646.2) not specified as acute or chronic, but with stated pathology or cause (583.0-583.9)

Diabetes mellitus, unspecified as to episode of care or not applicable 648.00 Diabetes mellitus, delivered, with or without mention of antepartum condition 648.01 Antepartum condition with delivery NOS (with mention of antepartum complication during current episode of care) Intrapartum obstetric condition (with mention of antepartum complication during current episode of care) Pregnancy delivered (with mention of antepartum complication during current episode of care) r P ractic e s

Diabetes mellitus, delivered, with mention of postpartum complication 648.02 ou

Delivery with mention of puerperal complication during current rc e / e

episode of care s c l i n

Diabetes mellitus, antepartum condition or complication 648.03 ic Antepartum obstetric condition, not delivered during the current episode of care

Diabetes mellitus, postpartum condition or complication 648.04 Postpartum or puerperal obstetric condition or complication following delivery that occurred: during previous episode of care outside hospital, with subsequent admission for observation or care Abnormal glucose tolerance, unspecified as to episode of care or not applicable 648.8

Abnormal glucose tolerance, delivered, with or without mention of antepartum 648.81 condition Antepartum condition with delivery NOS (with mention of antepartum complication during current episode of care) Intrapartum obstetric condition (with mention of antepartum complication during current episode of care) Pregnancy delivered (with mention of antepartum complication during current episode of care)

Abnormal glucose tolerance, delivered, with mention of postpartum 648.82 complication Delivery with mention of puerperal complication during current episode of care

Abnormal glucose tolerance, antepartum condition or complication 648.83 Antepartum obstetric condition, not delivered during the current episode of care

Abnormal glucose tolerance, postpartum condition or complication 648.84 Postpartum or puerperal obstetric condition or complication following delivery that occurred: during previous episode of care outside hospital, with subsequent admission for observation or care

166 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Billing and Coding Internet Resources:

• Code Manager® 2011, American Medical Association

• Physicians’ Current Procedural Terminology (CPT) 2011 http://www.ama-assn.org

• ICD-9-CM Official Guidelines for Coding and Report, October 2010 http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

• International Classification of Diseases, 9th Revision, (ICD-9-CM), 2011

• National Center for Health Statistics – Classification of Diseases and Functioning, and Disability http://www.cdc.gov/nchs/icd.htm

• Healthcare Common Procedure Coding System (HCPCS) American Medical Association 2011 https://www.cms.gov/MedHCPCSGenInfo/

• Medi-Cal/Medicaid Provider Manual www.medi-cal.ca.gov/

• Center for Medicare and Medicaid Services, Preventive Services Guidelines www.cms.hhs.gov/

• Palmetto GBA – Medicare Fiscal Intermediary, J1 MAC www.palmettogba.com/j1b

• Provider Manuals for Contracted Payers To obtain a copy of the provider manual from a specific payer, contact your local provider relations representative. Many health plans have electronic versions online. r P ractic e s ou rc e / e s c l i n ic

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46. National Insitutes of Diabetes Digestive and Kidney Disease (NIDDK). Prevent Diabetes Problems; Keep Your Feet and rc e /

Skin Healthy http://diabetes.niddk.nih.gov/dm/pubs/complications_feet/feet.pdf e s 47. Pan A, Lucas M, Sun Q, et al. Bidirectional association between depression and type 2 diabetes mellitus in women. c l i

Arch Intern Med. Nov 22 2010;170(21):1884-1891. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065781/pdf/nihms279192. n pdf ic 48. Naranjo DM, Fisher L, Arean PA, Hessler D, Mullan J. Patients with type 2 diabetes at risk for major depressive disorder over time. Ann Fam Med. Mar-Apr 2011;9(2):115-120. http://www.annfammed.org/cgi/reprint/9/2/115.pdf 49. Egede LE, Nietert PJ, Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care. Jun 2005;28(6):1339-1345. http://care.diabetesjournals.org/content/28/6/1339.full.pdf 50. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. Feb 2004;27(2):596-601. http://www.ncbi.nlm.nih.gov/pubmed/14747245 51. National Institutes of Diabetes Digestive and Kidney Disease (NIDDK). Prevent Diabetes Problems: Keep Your Teeth and

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 169 Gums Healthy, booklet 7: National Institutes of Health; 2008. http://diabetes.niddk.nih.gov/dm/pubs/complications_teeth/ 52. National Institutes of Diabetes Digestive and Kidney Disease (NIDDK). Prevent Diabetes Problems: Keep Your Eyes Healthy: NIH Publication; 2008. http://diabetes.niddk.nih.gov/dm/pubs/complications_eyes/ 53. National Insitutes of Diabetes Digestive and Kidney Disease (NIDDK). Prevent Diabetes Problems: Keep Your Kidneys Healthy: NIH Publication; 2006. http://diabetes.niddk.nih.gov/dm/pubs/complications_kidneys/ 54. National Institutes of Diabetes Digestive and Kidney Disease (NIDDK). Prevent Diabetes Problems: Keep Your Nervous System Healthy, booklet 6: National Institutes of Health; 2008. http://diabetes.niddk.nih.gov/dm/pubs/complications_nerves/ LP_PDP6_Nervous_System_Healthy_T.pdf 55. Smoking-Attributable Disease: A Report of the Surgeon General. 2010. http://www.surgeongeneral.gov/library/ tobaccosmoke/index.html 56. Centers for Disease Control. Smoking and Tobacco Use: Fact Sheet. 2008. http://www.cdc.gov/tobacco/data_statistics/ fact_sheets/index.htm 57. MacAller T, and California Diabetes Program. Be Proactive to Help Your Patients Quite Smoking, 2008. http://www. caldiabetes.org/content_display.cfm?ContentID=610 58. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. Sep 2008;53(9):1217-1222. http://www.ncbi.nlm.nih.gov/pubmed/18807274 59. California Diabetes Program and California Smokers Helpline. Do You CAARd? Diabetes Educators Toolkit. http://www. caldiabetes.org 60. American Dental Hygienists Association. Tobacco Cessation Protocols. 2006. www.askadviserefer.org/how_to_intervene. asp 61. International Diabetes Federation. Improving Patient Undetstanding of Type 2 Diabetes and the Benefits of the Multidiciplinary Team Approach. www.idf.org/webdata/docs/The_Multidisciplinary_Team.ppt 62. Indian Health Service. Patient-Provider Communication Toolkit, Ask Me 3. http://www.ihs.gov/healthcommunications/index. cfm?module=dsp_hc_toolkit 63. Travaline JM, Ruchinskas R, D’Alonzo GE, Jr. Patient-physician communication: why and how. J Am Osteopath Assoc. Jan 2005;105(1):13-18. http://www.jaoa.org/cgi/reprint/105/1/13.pdf 64. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. Jan 13 2003;163(1):83-90. http://archinte.ama-assn.org/cgi/reprint/163/1/83.pdf http:// archinte.ama-assn.org/cgi/content/full/163/1/83 65. Shawn Christopher Shea. Improving Medication Adherence: How to Talk with Patients About Their Medications: Lippincott Williams & Williams 2006. 66. The Permanente Medical Group Inc. Brief Negotiations Reference Card. 2010. 67. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. Aug 4 2005;353(5):487-497. http://www.ncbi.nlm.nih. gov/pubmed?term=Osterberg%20L%2C%20Blaschke%20T.%20Adherence%20to%20medication.%20N%20Engl%20J%20Med.%20 Aug%204%202005%3B353(5)%3A487-497.%20 68. Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Disord. 2006;6:48. http:// pubmedcentralcanada.ca/picrender.cgi?accid=PMC1762024&blobtype=pdf 69. Browyn Starr RS. Improving Outcomes for Patients With Chronic Disease: The Medication Adherence Project (MAP ). New York City Health and Human Services 2010. http://www.nyc.gov/html/doh/downloads/pdf/cardio/cardio-map-tools- manual.pdf 70. NYC Department of Health and Mental Hygiene. Improving Medication Adherence. City Health Newsletter2009: 1-8. http://www.nyc.gov/html/doh/downloads/pdf/chi/chi28-suppl4.pdf 71. American Medical Association. 2011 Professional Edition, ICD.9.CM. Vol 1 & 22011.

170 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Table Index Chapter 1 Table 1: Categories of Increased Risk for Diabetes (Prediabetes), 4 Table 2: Classification of Overweight/Obesity and BMI Table, 6 Table 3: Criteria for Clinical Diagnosis of Metabolic Syndrome, 8 Chapter 2 Table 4: Common Signs and Symptoms of Diabetes, 10 Table 5: Cardiovascular Disease Evaluation Consideration, 12 Table 6: Criteria for Testing for Diabetes in Asymptomatic Adults, 14 Table 7: Diagnosis of Diabetes, 15 Table 8: Signs and Symptoms of Severe Hypertension, 15 Table 9: Classification of Blood Pressure, 16 Table 10: Follow-up Recommendations Based on Initial BP Measures, 17 Table 11: Major and Modifiable Risk Factors, 17 Table 12: Classification of Lipid Profile, 18 Chapter 3 Table 13: Diabetes Care Guideline Flow Sheet, 21 Table 14: Correlation of A1c to mean Blood Glucose Values, 22 Table 15: Recommended Blood Glucose Treatment Goals, 23 Table 16: Household Sharps Waste Disposal Options, 25 Table 17: Oral Medications, 27 Table 18: Non-Insulin Injectables, 29 Table 19: DCC Insulin Guidelines, 30 Table 20: Insulin Injectables, 35 Table 21: Target Blood Pressure, 36 Table 22: Oral Blood Pressure Lowering Medications, 39 Table 23: Classification of Lipid Profile, 45 Table 24: Dyslipidemia Treatment Medications, 48 Table 25: Recommended Lifestyle Modifications, 56 Table 26: Modifiable Nutrients and Fats, 58 Chapter 4 Table 27: Acute Complications of Diabetes, Hypertension and Dyslipidemia, 60 Table 28: Common Long Term Complications of Diabetes, 61 Table 29: Symptoms of Depression, 66 Table 30: Monitoring Protocol for Patients on Atypical Antipsychotics, 67 Table 31: Dental Care Tips, 69 Table 32 : The Basics of the AAR, 74 Chapter 5 Table 33: Tips Toward a Better Provider-Patient Relationship, 77 Table 34: Choosing to Take Control of Diabetes, 78 Table 35: Readiness to Change - Patient Self Assessment, 78 Table 36: Tailor the Intervention, 82

Table 37: Tailor the Intervention, 85 r P ractic e Table 38: Brief Negotiations Reference Card, 89 s ou Table 39: Factors that Influence Adherence, 90 rc

Table 40: Addressing Common Barriers to Medication Adherence, 91 e / e s c

Chapter 7 l i n

Table 41: ICD 9-CM Coding for Diabetes Risk Factors and Cardiovascular Comorbid Diagnoses, 148 ic Table 42: ICD 9-CM Coding for Type II Diabetes Mellitus Diagnoses, 152 Table 43: ICD 9-CM Coding for Diabetes Related Complications and/or Comorbidities, 156 Table 44: HCPCS Codes Self Monitoring Blood Glucose Products, 157 Table 45: HCPS Codes Medicare Preventive and Screening Services, 158 Table 46: HCPCS Codes Self-Management Training Services, 162 Table 47: CPT Codes Medical Nutrition Therapy (MNT), 163 Table 48: ICD-9-CM Codes Supporting MNT,164

Chapter 2 Figure 2: Factors Contributing to Cardiometabolic Risk, 11

Chapter 3 Figure 3: Algorithm for Treatment of Hypertension, 37 Figure 4: JNC7 Reference Card, 43 Figure 5: ATP III Guidelines at a Glance, 50

Chapter 4 Figure 6: Foot Care Tips, 64 Figure 7: Diabetic Foot Exam, 65 Figure 8: Patient Health Questionnaire, 68

Chapter 5 Figure 9: Insulin Introduction Sample Dialogue, 86 Figure 10: Hypertension Self-Management Sample Dialogue, 88

Chapter 6 General Care and Management of Diabetes Figure 11: Your Diabetes Care Team, English, 97 Figure 12: Your Diabetes Care Team, Spanish, 98 Self Management Figure 13: Ask Doctor, English, 99 Figure 14: Ask Doctor, Spanish, 100 Figure 15: Diabetes Health Record, English, 101 Figure 16: Diabetes Health Record, Spanish, 102 Figure 17: Diabetes Health Record, Chinese, 103 Figure 18: My Health Goal, English, 104 Figure 19: My Health Goal, Spanish, 105 Figure 20: Help Loved Ones, 106 Assessing Risk and Prevention of Diabetes Figure 21: Tips to Help You Stay Healthy, 107 Figure 22: ADA Risk Test, English, 108 Figure 23: ADA Risk Test, Spanish, 109 Figure 24: ADA Risk Test, Chinese, 110 Glycemic Control Figure 25: Know Your Blood Sugar, English, 111 Figure 26: Know Your Blood Sugar, Spanish, 112 Figure 27: Symptoms Hypoglycemia, English, 113 Figure 28: Symptoms Hypoglycemia, Spanish, 114 Figure 29: Blood Glucose Log, English, 115 Insulin Management Figure 30: Myths/Fact Insulin, English, 116 Figure 31: Myths/Fact Insulin, Spanish, 117 Figure 32: Mealtime Insulin, English, 118

172 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes and Cardiovascular Disease Figure 33: Take Care of Your Heart, English, 119 Figure 34: How to Care for Your Heart, Spanish, 120 Figure 35: Diabetes, Smoking, and Your Health, English, 121 Figure 36: Diabetes, Smoking, and Your Health, Spanish, 122 Neuropathy Figure 37: Diabetes & Nerve Damage, English, 123 Figure 38: Diabetes & Nerve Damage, Spanish, 124 Nutrition Figure 39: Protect Your Heart, English, 125 Figure 40: Protect Your Heart, Spanish, 126 Figure 41: Cholesterol/Fat, English, 127 Figure 42: Cholesterol/Fat, Spanish, 128 Figure 43: Portion Size, English, 129 Figure 44: Portion Size, Spanish, 130 Exercise Figure 45: All About Physical Activity, English, 131 Figure 46: All About Physical Activity, Spanish, 132 Figure 47: Physical Activity You Need, English, 133 Medication Adherence Figure 48: Med Adherence Myth/Facts, English, 134 Figure 49: My Medication Log, English, 135 r P ractic e s ou rc e / e s c l i n ic

CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 173 E valuation

Your input is requested to help us improve future versions of the Diabetes and Cardiovascular Disease Provider Reference Guide (PRG). Please take a moment to complete this evaluation to improve the effectiveness and support the PRG provides you and your practice. The survey can also be accessed online at: http:www.zoomerang.com/Survey/WEB22CFZRUNESP/ Tell us about the PRG Please rate 1- 5 (5 - very satisfied, 4- satisfied, 3- neutral , 2- dissatisfied, 1- very dissatisfied) How would you rate your overall satisfaction with the content of the PRG? 5 4 3 2 1 How would you rate your satisfaction with each of these chapters? -Prevention and Delay of Type 2 Diabetes 5 4 3 2 1 -Screening and Diagnosis of Type 2 Diabetes, Hypertension and Dyslipidemia 5 4 3 2 1 -Comprehensive Management of Type 2 Diabetes 5 4 3 2 1 -Preventing and Managing Complications of Type 2 Diabetes 5 4 3 2 1 -Improving Type 2 Diabetes and Self Management 5 4 3 2 1 -Patient Resources 5 4 3 2 1 -Practice/ Clinic Resources 5 4 3 2 1 Please provide any recommendations to strengthen future versions to the PRG. ______Tell us about yourself and your practice Your answers to the following questions will help us assess whether we are addressing the needs of the various types of clinicians and practices that care for patients with diabetes. It will also help ensure a continued focus on reducing health disparities and access to care issues. State your practice is located in: ______

Practice type: Private practice Public Health Clinic Community Clinic/Community Health Center

Practice characteristics (check all that apply) Urban Rural Suburban Solo/Small group (1-4) Medium group (5-150) Large group (151-1000) Very large group (> 1000)

Your estimated percent of your patients diagnosed with type 2 diabetes? ______%

Your training: MD/DO PA NP Other: ______

Your race/ethnicity (optional): African American/Black Alaskan Native/Native American Asian Hispanic/Latino Native Hawaiian or Other Pacific Islander White OTHER ______

If you would like to receive notification of webinars, tools and other resources offered by the CMA Foundation’s Diabetes Quality Improvement Project, please provide your first and last name and email address. ______

Thank you for your assistance. Diabetes Quality Improvement Project Please fax or e-mail this survey to: Attention: Julie Vedolla-Fuentes Fax: (916) 779-6658 E-mail: [email protected]

174 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . jUly 2011 CMA Foundation . Diabetes and Cardiovascular Disease Provider reference guide . July 2011 Diabetes Quality Improvement Project

www.thecmafoundation.org [email protected] Tel 916-779–6620

Improving Medication

Adherence

• Definition of Adherence

• Methods of Measuring Adherence – Patterns of Medication Use

• Addressing Barriers to Adherence

– System Strategies for Improvement Communication Strategies for Improvement – – Policy Interventions

– Tools – Additional Resources

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33% - 50% of patients in the United States do not take their medications as prescribed,1 substantially worsening disease, death, and contributing to increased health care costs. 69% of all medication-related hospital admissions are due to poor medication adherence, with a resultant cost of approximately $100 billion a year. Generally, the ability of physicians to recognize non-adherence is poor and interventions to improve adherence have had mixed results.2

Drugs don’t work in patients who don’t take them.

- C. Everett Koop, MD

Definition of Adherence

Medication adherence is generally defined as the extent to which patients take medications as prescribed by their health care providers. Rates of adherence for individual patients are usually reported as the percentage of the prescribed doses of the medication actually taken by the patient over a specified period.3 Methods of Measuring Adherence

It can be challenging to measure patient medication adherence. Below is a partial list of methods, each with their own pros and cons. It is suggested that providers work with patients to select and implement the most valid method of assessment.4 There is no one ideal method for assessing and measuring adherence for all patients. Therefore, it may be worth combining more than one method when evaluating medication adherence for an individual patient.

Table 49: Methods of Measuring Adherence

Method Advantages Disadvantages

Patient/caregiver questionnaires Simple; inexpensive; the most Susceptible to error with increases and self-reports. useful method in the clinical in time between visits; results are setting. For some patients In easily distorted by the patient. Can Home Support Service workers be very time consuming. are great sources of adherence data. Pill counts. Objective, quantifiable, and easy Data easily altered by the patient to perform. (e.g., pill dumping). Rates of prescription refills. Objective; easy to obtain data. A prescription refill is not Many plans/provider groups have equivalent to ingestion of developed reports, which make medication. Usually, the this data easily accessible and information is collected from paid useful. claims so some fill data may not be included in these reports.

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Assessment of the patients’ Simple; generally easy to perform. Factors other than medication clinical response. adherence can affect clinical response. Patient diaries. Helps to correct for poor recall. Easily altered by the patient. Medication Adherence

Improving Medication dispensing systems Useful to help patients remember Expensive. such as prepackaged doses. and to see adherence problems.

Six Patterns of Medication Use

Medication use has been found to fall into six basic categories. These patterns may be helpful in identifying your patient’s category of typical use.5

 One-sixth come close to perfect adherence,

 One-sixth take nearly all doses, but with some timing irregularity,

 One-sixth miss an occasional single day’s dose and have some timing inconsistency,

 One-sixth take infrequent drug holidays, like three to four times a year,

 One-sixth have more frequent drug holidays, like monthly or more often, with frequent omissions of doses,

 One-sixth take few or no doses while sometimes giving the impression of good adherence. Addressing Barriers to Adherence

One approach is to think about improving medication adherence by addressing system approaches, communication strategies including addressing barriers to adherence,6 and policy interventions.7

System Strategies for Improvement

 Start by developing a workable process within your practice for assessing adherence with your patient and your staff from the list above such as pill counts, or using dispensing reports;

 Develop a routine where at every visit you (note: already included in the PRG):

o Ask patients to bring their in medications,

o Reconcile the patient’s medication list to include any additional medications they might be taking,

o Assess adherence by your chosen method and discuss possible barriers with your patients if necessary,

o Regularly reassess your process for assessing your patient’s medication adherence as you gain experience with improving adherence.

CMA FOUNDATION . DIABETES AND CARDIOVASCULAR DISEASE PROVIDER REFERENCE GUIDE . APRIL 2013 3

 Adjust doses or drugs and eliminate unneeded medication by prescribing once-daily formulations, less expensive generics and longer lasting medication supplies such as transdermal medications or more “forgiving” medications;

 Provide a system to help patients remember to take their medication as prescribed, such as pill boxes, blister packs and/or medication logs;

 Consider working with community pharmacists who offer programs for patients needing additional educational support. Face-to-face counseling to support adherence to medication therapy has been shown to be highly effective;

 Increase hours when the clinic is open (including evening hours). Lack of access to care is correlated with negative medication adherence, while shorter wait times have been correlated with positive medication adherence.

Communication Strategies for Improvement

 Look for predictors of non-adherence such as missed appointments (“no-shows”), lack of response to medication, missed refills;

 Emphasize the value of the regimen and the effects of adherence;

 Elicit patient’s feelings about his or her ability to follow the regimen, and if necessary, design supports to promote adherence;

 Provide simple, clear instructions and simplify the regimen as much as possible;

 Reinforce desirable behavior and results when appropriate;

 Obtain the help from family members, friends, and community services when needed;

 Consider meeting periodically with your high volume pharmacies to improve communication systems for high risk patients.

Policy Interventions

There are a variety of policy interventions that aim to improve medication adherence for chronic health conditions in the United States. However, evidence is limited on whether these approaches positively affect long-term medication adherence and health outcomes.8,9  Reduce out of pocket expenses and improve insurance coverage;

 Case Management - Proposals aimed at improving care coordination must recognize the important role that medications play in treating and managing illnesses;

 Quality Improvement – National quality improvement strategies should explicitly recognize medication adherence and appropriate medication use as critical components to improving health care quality and clinical outcomes;

 Health Information Technology – Health information technology must improve the flow of timely and

4 CMA FOUNDATION . DIABETES AND CARDIOVASCULAR DISEASE PROVIDER REFERENCE GUIDE . APRIL 2013 Medi Adhe Impr c o r

complete information between patients and providers, and enable providers and payers to identify gaps in patients’ medication use;

 Patient education with behavioral support – Strategies to improve medication adherence must fully engage patients, and patient-centered care must involve strategies to help them better understand their conditions and treatment. These efforts also must support providers in effective communication on the importance of following treatment plans, and in providing medication support services to patients and caregivers;

 Health Services Research – There is a need for additional research on medication adherence including a focus on the effectiveness of a wider range of interventions to improve adherence, as well as an analysis of the diverse factors, behaviors, costs and consequences related to poor adherence.

Tools

The “3 Cs” approach to medication adherence is an evidenced-based tool to help practitioners determine the risk of adherence problems and to provide suggestions for addressing issues raised by the survey.10 The three Cs are:  Concern – patient’s concern that prescription medication will do more harm than good,

 Commitment - patient’s belief that prescription medication is necessary,

 Cost – Some patients believe that prescription medications are not affordable.

Additional Medication Adherence Resources

 Improving Medication Adherence, Carl Sirio, M.D., University of Pittsburgh, Pittsburgh, PA, AHRQ Grant No. HS015851-01, Agency for Healthcare Research and Quality, 2005. http://www.ahrq.gov/qual/pips/sirio.htm. Medication Adherence Improving o The project implements a multi-modal patient medication education intervention to improve safety hospital-wide by involving clinicians and patients during the hospital stay. Drawing on health behavior change theory, the intervention focuses on reducing

30-day hospital readmissions and on improving patient satisfaction and medication adherence. The toolkit promotes a generalizable and sustainable education program with tools and resources that promote structured medication education, administrative support and staff training, and established quality improvement techniques. The toolkit includes CDs with training materials, Pocket/wallet-sized cards to promote health behavior Medication Adherence change guidelines, and Classroom training materials. Improving  Karl Uhlendorf , Many Paths to Improving Medication Adherence – New Study 09/14/2012 . PhRMA online publication. http://catalyst.phrma.org/many-paths-to-improving-medication-

adherence-new-study/.  Shawn Christopher Shea. Improving Medication Adherence: How to Talk with Patients About Their Medications: Lippincott Williams & Williams 2006.

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References

1. Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovas Disord.2006;6:48. http://pubmedcentralcanada.ca/picrender.cgi?accid=PMC1762024&blobtype=pdf. 2. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. Aug 4 2005;353(5):487-497. http://www.ncbi.nlm.nih.gov/pubmed/21942628 3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. Aug 4 2005;353(5):487-497. http://www.ncbi.nlm.nih.gov/pubmed/21942628 4. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. Aug 4 2005;353(5):487-497. http://www.ncbi.nlm.nih.gov/pubmed/21942628 5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. Aug 4 2005;353(5):487-497. http://www.ncbi.nlm.nih.gov/pubmed/21942628 6. Browyn Starr RS. Improving Outcomes for Patients With Chronic Disease: The Medication Adherence Project (MAP ). New York City Health and Human Services 2010. http://www.nyc.gov/html/doh/downloads/pdf/cardio/cardio-map-tools-manual.pdf. 7. Policy Recommendations for Improving Medication Adherence. Medical News Today. 28 Oct 2009. http://www.medicalnewstoday.com/releases/169004.php. 8. Viswanathan, M., et al. Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review. Ann Intern Med. 4 December 2012;157(11):785-795. http://annals.org/article.aspx?articleid=1357338#Discussion. 9. Policy Recommendations for Improving Medication Adherence. Medical News Today. 28 Oct 2009. http://www.medicalnewstoday.com/releases/169004.php. 10. The Adherence Estimator - The Adherence Estimator.® The Adherence Estimator is a patient-centered resource that can help you identify your patients who may be at risk of medication non-adherence. https://www.merckengage.com/hcp/rx-for-health/adherence-estimator.aspx.

6 CMA FOUNDATION . DIABETES AND CARDIOVASCULAR DISEASE PROVIDER REFERENCE GUIDE . APRIL 2013

The Medicare Stars Program

• Why Stars is Important

Effect on Plan Enrollment •

• Measures – Clinical Measures

– CMS Data

• Getting Started

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The Medicare Stars program is the pay-for-performance (P4P) program for Medicare Advantage (MA) plans. It has been developed by the Center for Medicare and Medicaid Services (CMS) starting in 2007 for MA plans that participate in Medicare Part C and Part D. These MA plans are awarded 1-5 Stars at the contract level for their results on 37 Part C and 18 Part D measures, which are rated individually and rolled up to a plan star rating on an annual basis. The ratings are posted on Medicare’s website (www.medicare.gov). Beneficiaries and CMS can assess plan performance.1

The Medicare Stars program is particularly important to solo and small group practices because:

 CMS star criteria are all good medicine. On the technical side, they are universally accepted as effective preventive and screening efforts. The patient engagement measures are what we all strive to do, too. We need to do better as a group.

 Your practice has already evolved from a “cottage industry” to a wired, responsive, information-rich advanced approach. You are already using staff members in more resourceful ways. This is just another step in a process you have already started.

 Good patient recall means a better chance of compliance with good medical advice. Reinforcement and consistency are important for seniors.

 Patient satisfaction may seem “soft,” but it has a great deal to do with your own practice and the group’s success. It’s not accidental, and plans need your help. In addition, patient experience measures are weighted 1.5 when plan’s ratings are calculated.

 The financial rewards will not be achieved unless the group as a whole performs well to contribute to the MA plan ratings. We will recognize and reward the leaders.

 Financial rewards for Stars could be equal or greater than P4P, if we do well on the measures. It’s not trivial dollars. Often times plans will utilize member incentives to complement provider incentives to maximize improvement.

 Medicare Advantage (MA) contracts are generally the ones which keep groups afloat. Our financial security could be threatened if our Star scores do not surge upwards. It’s a fact of life that both the individual doctor and the group would be hard pressed to replace the revenue that comes directly from Medicare Advantage.

The Bottom Line for solo and small group practices:

 It’s good medicine,

 It’s good business for you and your group,

 It meshes with your current work flow,

 4+ Stars is what you would want for your parents.

The Medicare Stars program is also important to plans because CMS is eliminating the 14% of the additional revenues plans have had over Fee-for-Service (FFS) in the coming years. Plans can earn through performance what they are losing in prospective cap rates. Starting in 2012, plans with 4 or more Stars receive a bonus and higher rebates. Plans with 3 or less Stars for 3 years will be flagged as consistently low performers by CMS on the Plan Finder at medicare.gov. After three years in a row, potential enrollees are given a caution to look

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closely at this plan before enrolling. Plan performance financially affects all groups contracted with a plan because often group contracts are a percentage of the plan’s MA premium.2

Plans with four Stars or more will receive a sizable bonus, some of which may be shared with their practices:  In 2012 the plans received an additional 1.5%,  In 2013 the plans will receive an additional 3%,  And in 2014 the plans will receive an additional 5%.3

Effect on Plan Enrollment

A recent study answered the question about the effect of the STAR ratings on plan enrollment; it found an association between a plan’s Star rating and beneficiaries’ enrollment decisions among almost 1 million new enrollees and 322,000 enrollees switching plans. For new enrollees, a 1-star higher rating was associated with a 9.5% increased likelihood to enroll. For enrollees switching plans, a 1-star higher rating was associated with a 4.4 % increased likelihood to switch and enroll in the higher rated plan. This finding supports the notion that a plan’s Star rating is important to enrollees and at least in part affects decisions to enroll in a plan or to switch from one plan to another.4

Diabetes measures are a significant portion of the Medicare Star measures, and improvement will help a plan achieve 4 or 5 Star rating. In addition, the processes a site uses to implement diabetes improvements will help with other measures/focused areas. Focusing on Stars will also help groups and practices perform better for commercial and Medi-Cal members. Measures

There are currently 37 Part C 3 and 5 Part D Stars metrics that are measured on an annual basis. Six of the measures are devoted to diabetes care.5

Clinical Measures – HEDIS or CMS Methodology  Breast Cancer Screening,  Colorectal Screening,

 CV Cholesterol Screening, Stars Medicare

 Diabetes - Cholesterol Screening, Program  Diabetes - Kidney Monitoring,  Diabetes - Blood Sugar Control,

 Diabetes - Cholesterol Control,  Diabetes Eye Care,  Glaucoma Testing,  Access to Primary Care Doctor Visits,  Osteoporosis Management for Women with a Fracture,  Controlling Blood Pressure,  Rheumatoid Arthritis Management,  All Cause Readmissions,  Adult BMI Assessment,

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 Care for Older Adults – Medication Review (SNP plans only)  Care for Older Adults - Functional Status Assessment (SNP plans only),  Care for Older Adults - Pain Screening (SNP plans only).

Part D Measures  High Risk Medication,  Diabetes Treatment (diabetics with hypertension who were dispensed and ACEI or ARB),  Medication Adherence – Oral Diabetes Meds,  Medication Adherence – ACEI/ARB for Hypertension,  Medication Adherence – Statin for High Cholesterol.

Health Outcomes Survey®a  Improving Bladder Control,  Reducing the Risk of Falling,  Monitoring Physical Activity,  Improving or Maintaining Physical Health,  Improving or Maintaining Mental Health.

CAHPS®b  Annual Flu Vaccine,  Pneumonia Vaccine (not included in plan ratings as of 2013 but is a display-only measure),  Ease of Getting Needed Care from Specialists,  Getting Appointments and Care Quickly,  Overall Rating of Quality,  Overall Rating of Plan,  Customer Service,  Care Coordination.

CMS Datac  Complaint about the Plan  Plan Makes Timely Decisions  Fairness of Plan’s Denials  Members Leaving the Plan  Availability of TTY/TDD and Interpretation  Access and Performance Problems.

a The Health Outcomes Survey® (HOS) is administered by CMS annually to obtain data for the first four measures in the table. The results are based on patient recall for each topic. Ratings for the last two measures are derived from responses to questions administered bi-annually to the same cohort of members. Functional status results from the baseline survey are compared to responses on the follow-up survey to assess decline in functional status. Functional status questions are based on patient perception of physical and mental health status. b The Consumer Assessment of Healthcare Providers & Systems® (CAHPS) is administered annually by certified survey vendors hired by health plans. The first two questions in the table rely on patient recall of flu and pneumonia vaccines rather than administrative (claim/encounter) or medical record review data. c This information is submitted by the plans to CMS.

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Getting Started

For health care organizations, including solo and small group practices, that would like to improve on the Medicare Stars Program results, here are some evidenced based tips for getting started:

 Utilize a data warehouse or a registry. If you currently have a registry work with your staff to align information so that your practice can identify patients with gaps in care and conduct outreach to those patients to receive needed services. If your Electronic Record does not have a registry or you do not currently use a registry, consider contacting your Medicare Advantage (MA) Plan. Ask the plan to provide you with data available to the plan that can function as a population based tool. The plan may also be able to provide technical assistance and expertise to help you in this area.  Make sure you include your Medicare patients in your registry. Often plans will include only your commercial or Medicaid members in their database. Work with the plan to design a database that can include data for all of your patients.  Produce exception reports for MA Stars metrics. Once you have a functioning data warehouse or registry design exception reports to identify patients needing services such as diabetic labs or imaging studies.  Create an action plan to address gaps in care (outreach to members, etc.). Working with your office staff, develop a team based approach to care with each staff person having assigned tasks to ensure effective interventions to address patients needing services.  Conduct planned/prepared visits. As part of your team based approach, design or redesign your daily work flow so that each patient visit maximizes outcomes for members with the chronic conditions pertinent to the Stars Program.  Work across your entire organization to meet targets. Set realistic, achievable goals and monitor and track your progress toward those goals. Schedule frequent, short huddles or team meetings with your entire office staff to keep your identification, outreach, and interventions on target. Make sure you regularly celebrate your successes.  Collaborate with health plans.6 Most plans are anxious to partner with their contracted providers to improve. These plans may offer financial incentives for improvement or results as well as being willing to provide technical assistance to your practice on how to improve.  Apply proven changes that other groups/practices have implemented to improve performance. The California Quality Collaborative’s Clinical Quality Improvement Toolkit includes changes at the group/IPA level, the clinical office practice level, and methods to engage patients. The toolkit is available at http://www.calquality.org/documents/ClinicalQualityImprovement_Toolkit_FA.pdf.

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References

1. Medicare Health & Drug Plan Quality and Performance Ratings. 2013 Part C & Part D Technical Notes, http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2013- Part-C-and-D-Preview-2-Technical-Notes-v100212-.pdf. 2. CQC’s Medicare StarQuest Change Package: http://www.calquality.org/programs/clinicalcare/pastprogs/documents/starquest/Change_Package- Clinical_Metrics.pdf. 3. CQC Medicare StarQuest conference program resources: http://www.calquality.org/programs/clinicalcare/pastprogs/starquest.html. 4. Primer: CMS Star Ratings for Medicare Advantage Plans at www.calquality.org/programs/clinicalcare/.../4_StarsPrimerforGroups.pptx. 5. Reid, Rachel O., Deb, Partha, Howell, Benjamin L., and Shrank, William H., Association Between Medicare Advantage Plan Star Ratings and Enrollment. JAMA, January 16, 2013 – Vol. 309, Nov 3. (p 267- 274). 6. Medicare Stars Measures, Differences Between the 2011 Plan Ratings and 2012 Plan…For Assigning Part C and D Measure Star Ratings; Aug 4, 2011. www.calquality.org/documents/Technical_Notes_2012.pdf. 7. Presenting CMS Stars to Practicing PCP's at http://www.calquality.org/programs/clinicalcare/resources/documents/Presenting_CMS_Stars_to_Practicing _PCPs.pdf.

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