ADA Releases Revised Clinical Practice Guidelines

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By Brian McCurdy

The American Diabetes Association (ADA) recently released its revisions of the 2002 Clinical Practice Recommendations. Will these revisions lead to improved clarity, better outcomes and a heightened awareness of diagnostic indicators among all health care professionals? Those in the know seem to have a favorable impression. “Two of the association’s most critical position statements have been completely revised and several others have been updated, using the ADA’s system for grading scientific evidence to support clinical practice recommendations,” says Lee Sanders, DPM, the Former President of Health Care and Education for the ADA. The rewritten position statements are the “Standards of Medical Care for Patients with Diabetes” and “Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Complications.” Dr. Sanders says the “Standards of Medical Care” detail specific goals of treatment, at diagnosis and in continuing care, and offers recommendations concerning complications and particular patient groups, such as the elderly, children and pregnant women. He adds that the “Nutrition Principles” outline the ADA’s goals and recommendations for nutrient composition, energy balance, alcohol and micronutrients in patients who have type 1 or type 2 diabetes. “I feel the position statements by the ADA are right on the money in that they target the essential points of managing the diabetic foot,” says Tamara Fishman, DPM. “From a practical standpoint, most, if not all, podiatrists are aware of the risk diabetic patients have for infections and amputations. However, I feel many other specialists will benefit tremendously from this information, especially primary care physicians.” Dr. Fishman, the Chairman of the Wound Care Institute in Florida, says most primary care doctors never ask patients about their feet or examine them. Other changes from the ADA include the unveiling of a new position statement on “Treatment of Hypertension in Adult Patients with Diabetes Mellitus,” and a terminology change that replaced “HbA1C” with the simpler “A1C” to denote the test for long-term glycemic control. However, ADA’s position statement on “Preventive Foot Care in People With Diabetes” (based on a 1998 Diabetes Care paper) remains unchanged. As Dr. Sanders notes, these foot care guidelines have been adopted by the American Podiatric Medical Association and the American Orthopedic Foot and Ankle Society. “Fundamental to preventive management of the foot in people with diabetes is risk identification,” says Dr. Sanders. “There is an increased risk of foot ulcers and amputations in people who have diabetes for 10 years or longer, are male, have poor glucose control, or who have cardiovascular, retinal or renal complications.” Given the heightened risk of foot ulcers and amputations, Dr. Sanders says DPMs should be particularly vigilant when they see patients who have peripheral neuropathy with loss of protective sensation; altered biomechanics (with neuropathy); increased plantar pressure; and/or peripheral vascular disease. For more information on the 2002 Clinical Practice Recommendations, see the ADA Web site, www.diabetes.org. Can A1c Screening Improve Early Detection Of Diabetes? Roughly five million Americans have undiagnosed diabetes, according to a recent study published in the January issue of the Journal of General Internal Medicine. This highly undiagnosed population prompted the study’s researchers to conduct hemoglobin A1c (HbA1c) testing on 1,200 men and women patients between the ages of 45 and 64. The patients had not been diagnosed with diabetes but were under a doctor’s care. Researchers found that nearly 5 percent of those tested had type 2 diabetes. The study’s results suggested the A1c test catches more cases of diabetes than other well-known tests such as the fasting plasma glucose test. While the A1c test has been used to test for type 2 diabetes for some time, the study indicated that targeting certain patients with routine screening, using this test, may lead to an early diagnosis. Clearly, there is a strong need for early diagnosis as statistics on the potential prevalence of Type 2 diabetes continue to rise. Researchers from the Centers for Disease Control and Prevention (CDC) estimate 47 million Americans are at risk for type 2 diabetes.

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