Special Diabetes Program for Indians (SDPI)

Strong Family Health Center’s Special Diabetes Program for Indians chooses a “Best Practice” provided by The IHS Division of Diabetes for each grant cycle period. The overall goal is to provide information and resources to strengthen clinical, public health, and community approaches to diabetes treatment and prevention in American Indians and Alaska Natives.

Individuals can experience different signs and symptoms of diabetes, and sometimes there may be no signs. Some of the signs commonly experienced include:

• Frequent urination
• Excessive thirst
• Increased hunger
• Weight loss
• Tiredness
• Lack of interest and concentration
• A tingling sensation or numbness in the hands or feet
• Blurred vision
• Frequent infections
• Slow-healing wounds
• Vomiting and stomach pain (often mistaken as the flu)

The development of type 1 diabetes is usually sudden and dramatic while the symptoms can often be mild or absent in people with type 2 diabetes, making this type of diabetes hard to detect.

If you show these signs and symptoms, consult a health professional.

A goal of the SFHC Diabetes Program is that all participants receive at least yearly:

• Physical Exam
• Eye Exam with Dilation
• Dental Exam and Bi-Annual Cleaning
• Depression and Alcohol Screening
• Laboratory Test for A1c, Cholesterol and Kidney Function
• Immunizations for Influenza, Pneumonia, Hepatitis B, Tetanus and Zoster (Shingles), Respiratory Syncytial Virus (RSV)
• PAD Screening
• Mammogram
• Regular: Diabetes and Nutrition Education, Foot Exams and Vitals Check

If interested in the Diabetes Program or for more information contact SFHC at 530-233-4591 or email mrichno@modocsfhc.org

• Specify Type 1 or Type 2
• Male or Female
• Date of Diabetes Onset or Date of Diagnosis
• Date of Birth
• Height and Weight
• Medication List
• Current A1c
• Primary Medical Doctor

Labs

Cholesterol:

Obtain a lipid panel (total cholesterol, LDL, HDL, triglycerides) at diagnosis of diabetes. Implement a plan to achieve lipid management goals which includes Lifestyle therapy, nutrition and physical activity, weight management, and smoking cessation, is indicated for all patients with type 2 diabetes, even those with “normal” lipid levels.

Chronic Kidney Disease (CKD):

Obtain a serum creatinine/estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) at diabetes diagnosis and then at least annually thereafter.

Consider nephrology consultation for chronic kidney disease (CKD) if CKD is progressing rapidly. Try to achieve an individualized blood pressure target of, < 130/80 mmHg for all patients with diabetes:

Blood Glucose Test (A1C):

Perform A1C testing every 3 to 6 months in “stable” patients to monitor progress toward clinical targets. A1C testing may be repeated as soon as 1 month later to assess response to initiation or a change in therapy.

A1C is a “weighted” measure of glycemic control over the preceding 120 days. The more recent days contribute a greater percentage to the measure than the distant days. Specifically, the mean level of blood glucose in the 30 days immediately preceding the test contributes approximately 50% of the final result

Vision

People with diabetes are at lifelong risk for eye and vision problems, including diabetic retinopathy, cataracts, glaucoma, age-related macular degeneration, and blindness. Good control of glucose and blood pressure helps to prevent onset and reduce progression of diabetic retinopathy. In addition, early detection, monitoring, and treatment of retinopathy are essential to reducing the risk of blindness.

A retinal examination should be used to detect retinopathy. Although serious vision loss due to diabetes can nearly be eliminated through timely diagnosis and treatment, only about half of all AI/AN people with diabetes receive an annual retinal examination.

Dental

People with diabetes frequently have problems with their teeth and gums, especially when they have poor glycemic control. The higher the blood glucose, the greater the risk for developing periodontal disease. AI/AN people with diabetes have two to three times more advanced periodontal disease than people who do not have diabetes.

Periodontitis can negatively affect diabetes control and development of diabetes complications. The infection and inflammation associated with periodontitis can aggravate blood glucose control and increase risk for many of the complications of diabetes such as CVD and CKD.

Blood Pressure

Measure blood pressure at diabetes diagnosis and at every visit. Adults with diabetes and hypertension should be treated to a blood pressure goal of <140/<90 mmHg.

Therapeutic lifestyle changes, including nutrition therapy and physical activity, are recommended to reduce blood pressure.

Blood pressure control reduces the risk for diabetes complications, including cardiovascular disease and chronic kidney disease, and is essential in diabetes care.

Some factors that can affect accurate blood pressure readings, include but are not limited to patient positioning, cuff size and placement, and recent caffeine and tobacco use.

Foot Care

Foot ulcers and amputations due to diabetic neuropathy and/or peripheral arterial disease (PAD) are common, yet often preventable causes of disability in adults with diabetes. Because early identification and management of patients at high risk for foot problems can prevent or delay the onset of adverse outcomes, it is important to evaluate the feet of all patients with diabetes.

All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. People with one or more high-risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every visit with a health care professional.

Peripheral Artery Disease (PAD)

PAD is atherosclerosis of arteries to the head, organs, and limbs. PAD manifests most commonly in patients with diabetes as symptoms of leg claudication. If left untreated, PAD can progress to critical leg ischemia that can threaten limb viability. Moreover, PAD is a marker of systemic atherosclerosis, indicating patients are at increased risk for myocardial infarction (MI), stroke, and death. Risk factors associated with PAD include older age, cigarette smoking, diabetes, hypercholesterolemia, hypertension, and possibly genetic factors.

Neuropathy

Neuropathy is a common complication of diabetes affecting multiple organ systems, and is a significant cause of morbidity and mortality. Poor blood glucose control and smoking can significantly increase the risk of neuropathy and its complications. There is no specific treatment for the nerve damage associated with diabetic neuropathy. Improving glycemic control may slow progression, but does not reverse nerve loss.

There are two main types of diabetic neuropathy: Peripheral neuropathy and autonomic neuropathy.

Peripheral neuropathy, most commonly affects the feet and legs in people with diabetes, and is the major cause of lower extremity problems, including pain, ulceration, and amputations.

Autonomic neuropathy is responsible for various cardiovascular, gastrointestinal, and genitourinary clinical problems such as: resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, and sudomotor dysfunction.

Nutrition

Nutrition Education by a Registered Dietitian includes individualized assessment, intervention, monitoring, and follow-up of nutrition interventions specific to the management and treatment of diabetes. Nutrition Education intensive nutrition counseling and therapy that relies heavily on follow-up and feedback to change behavior over a period of time.

There is good evidence that Nutrition Education is effective at any time in the disease process, but it appears to have its greatest effect in lowering A1C at initial diagnosis.

A major factor that prevents many people with diabetes from adhering to Nutrition Guidelines is food insecurity. Nearly half of all households below the poverty level in the U.S. are food insecure, including AI/AN. Food insecurity means these families are at risk of going hungry because of an inability to find or afford adequate food. In terms of diabetes, food insecurity creates a major barrier to managing and preventing diabetes effectively, and contributes to health disparities and disease burden.

Weight

Obesity and overweight, increasingly prevalent risk factors among AI/AN with diabetes, increase insulin resistance, and raise blood glucose levels. In turn, they exacerbate diabetes complications and make diabetes management more complex. Therapeutic lifestyle changes designed to achieve weight loss are the core components of weight management counseling, and are essential for managing diabetes and its comorbidities.

Physical Activity

Physical activity is important for achieving glycemic control goals, and it is a core component of diabetes self-management. Physical activity improves strength and endurance, improves insulin action, lowers blood glucose levels, improves body mass index, and reduces depression. Any increase in physical activity – from daily living, occupational pursuits, and structured aerobic or resistance exercise – is beneficial for patients.

Recommended Immunizations

• • Hepatitis B vaccination for unvaccinated adults, 3-dose series:
    Administer to adults <60 years of age: as soon as feasible after diabetes diagnosis.
  • Zoster (Shingles) vaccination for unvaccinated patients:
    Administer to adults ≥60 years of age as a single dose, regardless of reported history of prior herpes zoster episode.
  • Influenza (Flu) Administer annual influenza immunization to all patients’ ≥6 months of age.
  • Tetanus and Diphtheria (Td)
    Provide every 10 years; tetanus, diphtheria, and acellular pertussis (Tdap) should replace a single dose of Td for anyone who has not previously received a dose of Tdap.
  • Pneumococcal (Pneumonia)
    PCV13 is recommended all adults 65 years or older. PPSV is recommended for all adults who are 65 years or older who are at high risk for pneumococcal disease.
  • Respiratory Syncytial Virus (RSV)
    RSV vaccination is recommended for adults 60 years or older and individuals with a chronic medical condition such as diabetes.