Search

We present a case of an African-American child with vitamin D-deficient rickets. In addition to being solely breast-fed for the period of 1 year, he resided in New England, where exposure to ultraviolet light is limited owing to its northern latitude and long cold winters. He presented with classical signs of nutritional rickets and was immediately responsive to treatment with vitamin D supplementation.

Medical nutrition therapy (MNT) is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of diabetes prevention. MNT is also an integral component of diabetes self-management education (or training). This position statement provides evidence-based recommendations and interventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 and modified slightly in 2004. This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available...

OBJECTIVE—The American Diabetes Association (ADA) lists seven symptoms of diabetes; however, it is not known how specific these symptoms are for initial diagnosis of type 2 diabetes. The Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) examined prevalence of ADA symptoms and their association with diabetes diagnosis.RESEARCH DESIGN AND METHODS—SHIELD is a 5-year observational study of individuals with or at risk for diabetes diagnosis. Following an initial screening phase, follow-up questionnaires were mailed to a stratified random sample of individuals (n = 22,001) with type 1 or type 2 diabetes or at high (three to five risk factors) or low (zero to two risk factors) risk for diabetes. Individuals reported whether they experienced each ADA symptom, as well as symptoms unrelated to diabetes.RESULTS—A total of 15,794 questionnaires were returned (response rate 71.8%). All ADA symptoms were reported more frequently in type 2 diabetes than in low- and high-risk groups (P < 0.0001 for each). Multivariable logistic regression analyses found that each ADA symptom other than irritability was significantly associated with type 2 diabetes, as was erectile/sexual dysfunction. However, 48% of type 1 diabetic and 44% of type 2 diabetic respondents reported no ADA symptom in the previous year.CONCLUSIONS—Occurrence of ADA symptoms alone may not adequately identify those who should be evaluated for type 2 diabetes. Longitudinal data from SHIELD will evaluate whether combinations of symptoms or addition of other symptoms can better identify individuals for evaluation.

The American Heart Association (AHA) and the American Diabetes Association (ADA) have each published guidelines for cardiovascular disease prevention: the ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. This statement will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which AHA and ADA recommendations differ.

During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. Recommendations regarding children and adolescents have generally been included as only a minor portion of these documents. For example, the most recent ADA position statement on “Standards of Medical Care for Patients With Diabetes Mellitus” (last revised October 2003) included “special considerations” for children and adolescents (1). Other position statements included age-specific recommendations for screening for nephropathy (2) and retinopathy (3) in children with diabetes. In addition, the ADA has published guidelines pertaining to certain aspects of diabetes that apply exclusively to children and adolescents, including care of children with diabetes at school (4) and camp (5) and a consensus statement on type 2 diabetes in children and adolescents (6). The purpose of this document is to provide a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus (7). Several excellent detailed guidelines and chapters on type 1 diabetes in pediatric endocrinology texts exist, including those by the International Society of Pediatric and Adolescent Diabetes (ISPAD) (8), by the Australian Pediatric Endocrine Group (www.chw.edu/au/prof/services/endocrinology/apeg), in Lifshitz’s Pediatric Endocrinology (9–11), and by Plotnick and colleagues (12,13). Children have characteristics and needs that dictate different standards of care. The management of diabetes in children must take the major differences between children of various ages and …

Diabetes has long been viewed as a disorder of carbohydrate metabolism due to its hallmark feature of hyperglycemia. Indeed, hyperglycemia is the cause of the acute symptoms associated with diabetes such as polydypsia, polyuria, and polyphagia (1). The long-term complications (retinopathy, nephropathy, and neuropathy) associated with diabetes are also believed to result from chronically elevated blood glucose levels (2–6). In addition, hyperglycemia may contribute to the development of macrovascular disease, which is associated with the development of coronary artery disease, the leading cause of death in individuals with diabetes (7–9). Thus, a primary goal in the management of diabetes is the regulation of blood glucose to achieve near-normal blood glucose. Blood glucose concentration following a meal is determined by the rate of appearance of glucose into the blood stream (absorption) and its clearance/disappearance from the circulation (10). The rate of disappearance of glucose is largely influenced by insulin secretion and its action on target tissues (11). The component of the diet that has the greatest influence on blood glucose is carbohydrate. Other macronutrients in the diet, i.e., fat and protein, can influence the postprandial blood glucose level, however. For example, dietary fat slows glucose absorption, delaying the peak glycemic response to the ingestion of a food that contains glucose (12–14). In addition, although glucose is the primary stimulus for insulin release, protein/amino acids augment insulin release when ingested with carbohydrate, thereby increasing the clearance of glucose from the blood (15–17). Both the quantity and the type or source of carbohydrate found in foods influence postprandial glucose level (18,19). Although most experts agree that the total carbohydrate intake from a meal or snack is a relatively reliable predictor of postprandial blood glucose (18,20–22), the impact …

Overweight and obesity are important risk factors for type 2 diabetes. The marked increase in the prevalence of overweight and obesity is presumably responsible for the recent increase in the prevalence of type 2 diabetes. Lifestyle modification aimed at reducing energy intake and increasing physical activity is the principal therapy for overweight and obese patients with type 2 diabetes. Even moderate weight loss in combination with increased activity can improve insulin sensitivity and glycemic control in patients with type 2 diabetes and prevent the development of type 2 diabetes in high-risk persons (ie, those with impaired glucose tolerance). The American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition have joined together to issue this statement on the use of lifestyle modification in the prevention and management of type 2 diabetes.

The prevalence of diabetes in the U.S. continues to rise by epidemic proportions. This increase parallels the rising rates of obesity and overweight observed over the past decade (1,2). Indeed, as BMI increases, the risk of developing type 2 diabetes increases in a “dose-dependent” manner (3,4). The prevalence of type 2 diabetes is 3–7 times higher in obese than in normal-weight adults, and those with a BMI >35 kg/m2 are 20 times more likely to develop diabetes than those with a BMI between 18.5 and 24.9 kg/m2 (5,6). In addition, weight gain during adulthood is also directly correlated with an increased risk of type 2 diabetes (3,7–9). Obesity also complicates the management of type 2 diabetes by increasing insulin resistance and blood glucose concentrations (10). It is an independent risk factor for dyslipidemia, hypertension, and cardiovascular disease (6,11–14) and, thus, increases the risk of cardiovascular complications and cardiovascular mortality in patients with type 2 diabetes (15). The purpose of this statement is to review the important role of weight management in the prevention and management of type 2 diabetes and to describe strategies for achieving and maintaining a healthy body weight through lifestyle modification. The use of weight loss medications and bariatric surgery in the management of obesity will not be discussed in this document. Pharmacotherapy can be a useful adjunct to lifestyle modification in the long-term management of obesity in selected patients (16). Weight loss medications may be considered for those with a BMI ≥30 or those with a BMI ≥27 plus obesity-related comorbid conditions. Weight loss surgery may be a therapeutic alternative for patients with a BMI ≥40 or a BMI ≥35 plus comorbid conditions (16). Comprehensive review articles that …

Cavalot F, Pagliarino A, Valle M, Di Martino L, Bonomo K, Massucco P, Anfossi G, Trovati M: Postprandial blood glucose predicts cardiovascular events and all-cause mortality in type 2 diabetes in a 14-year follow-up: lessons from the San Luigi Gonzaga Diabetes Study. Diabetes Care 34:2237–2243, 2011 Objective. To evaluate whether postprandial blood glucose (PPG) levels predicted cardiovascular disease (CVD) events and all-cause mortality in people with type 2 diabetes in a long-term follow-up study. Design. Consecutive patients with type 2 diabetes ( n = 505; age 62 ± 10 years, diabetes duration 9 ± 8 years) were followed for 14 years. The relationship between CVD events and five glycemic control parameters (fasting blood glucose [FBG], blood glucose 2 hours after breakfast and lunch, pre-dinner blood glucose, and A1C) were analyzed looking at all-cause mortality and first cardiovascular event during the 14-year follow-up period. Results. Cardiovascular events occurred in 34% and death occurred in 29% of the study population. When the five glycemic control parameters were considered together, the major predictor of cardiovascular events was blood glucose measured 2 hours after lunch. That measurement and A1C were the strongest predictors of all-cause mortality. When blood glucose level 2 hours after lunch and A1C were considered together with the main CVD risk factors, the results were the same. Conclusion. Both PPG and A1C predicted cardiovascular events and mortality in this long-term follow-up study. This study, a follow-up to an earlier report,1 is important because it examined the effect of PPG (i.e., blood glucose measured 2 hours after a meal) compared to blood …

Diabetes mellitus is the seventh leading cause of death in the United States, with a total annual economic cost estimated at $98 billion. Diabetes is caused by either a lack of insulin secretion or by insulin resistance. The resultant metabolic disturbance leads to hyperglycemia and dyslipidemia in the short term, as well as long-term complications such as retinopathy, neuropathy, and nephropathy. In addition, individuals with diabetes are 2 to 4 times more likely to develop coronary artery disease or to suffer a stroke. Findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) clearly indicate that the maintenance of near-normal blood glucose concentration dramatically reduces the chronic complications associated with this disorder. In addition, reducing elevated blood lipid levels has been shown to lower the incidence of acute coronary events in other at-risk populations. Finally, obesity, yet another diet-related disorder, is strongly associated with the development of Type 2 diabetes. Thus, nutrition therapy plays an important role in both the development and the management of diabetes. Appropriate modification and monitoring of food intake can assist with weight management as well as with the control of both blood glucose and lipid levels. Although insulin and/or oral medications are frequently required to treat diabetes, nutrition therapy remains an important tool in the management of this disease and should always be considered the cornerstone of therapy.

More than 25% of the U.S. population aged ≥65 years has diabetes (1), and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization (2). Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions: 1. What is the epidemiology and pathogenesis of diabetes in older adults? 2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults? 3. What current guidelines exist for treating diabetes in older adults? 4. What issues need to be considered in individualizing treatment recommendations for older adults? 5. What are consensus recommendations for treating older adults with or at risk for diabetes? 6. How can gaps in the evidence best be filled? According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria …

The American Diabetes Association (ADA) lists seven symptoms of diabetes; however, it is not known how specific these symptoms are for initial diagnosis of type 2 diabetes. The Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) examined prevalence of ADA symptoms and their association with diabetes diagnosis.SHIELD is a 5-year observational study of individuals with or at risk for diabetes diagnosis. Following an initial screening phase, follow-up questionnaires were mailed to a stratified random sample of individuals (n = 22,001) with type 1 or type 2 diabetes or at high (three to five risk factors) or low (zero to two risk factors) risk for diabetes. Individuals reported whether they experienced each ADA symptom, as well as symptoms unrelated to diabetes.A total of 15,794 questionnaires were returned (response rate 71.8%). All ADA symptoms were reported more frequently in type 2 diabetes than in low- and high-risk groups (P0.0001 for each). Multivariable logistic regression analyses found that each ADA symptom other than irritability was significantly associated with type 2 diabetes, as was erectile/sexual dysfunction. However, 48% of type 1 diabetic and 44% of type 2 diabetic respondents reported no ADA symptom in the previous year.Occurrence of ADA symptoms alone may not adequately identify those who should be evaluated for type 2 diabetes. Longitudinal data from SHIELD will evaluate whether combinations of symptoms or addition of other symptoms can better identify individuals for evaluation.

Background Studies derived from continuous national surveys have shown that the prevalence of diagnosed diabetes mellitus in the US is increasing. This study estimated the prevalence in 2004 of self-reported diagnosis of diabetes and other conditions in a community-based population, using data from the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD). Methods The initial screening questionnaire was mailed in 2004 to a stratified random sample of 200,000 households in the US, to identify individuals, age ≥ 18 years of age, with diabetes or risk factors associated with diabetes. Follow-up disease impact questionnaires were then mailed to a representative, stratified random sample of individuals (n = 22,001) in each subgroup of interest (those with diabetes or different numbers of risk factors for diabetes). Estimated national prevalence of diabetes and other conditions was calculated, and compared to prevalence estimates from the National Health and Nutrition Examination Survey (NHANES) 1999–2002. Results Response rates were 63.7% for the screening, and 71.8% for the follow-up baseline survey. The SHIELD screening survey found overall prevalence of self-reported diagnosis of diabetes (either type 1 or type 2) was 8.2%, with increased prevalence with increasing age and decreasing income. In logistic regression modeling, individuals were more likely to be diagnosed with type 2 diabetes if they had abdominal obesity (odds ratio [OR] = 3.50; p < 0.0001), BMI ≥28 kg/m2 (OR = 4.04; p < 0.0001), or had been diagnosed with dyslipidemia (OR = 3.95; p < 0.0001), hypertension (OR = 4.82; p < 0.0001), or with cardiovascular disease (OR = 3.38; p < 0.0001). Conclusion The SHIELD design allowed for a very large, community-based sample with broad demographic representation of the population of interest. When comparing results from the SHIELD screening survey (self-report only) to those from NHANES 1999–2002 (self-report, clinical and laboratory evaluations), the prevalence of diabetes was similar. SHIELD allows the identification of respondents with and without a current diagnosis of the illness of interest, and potential longitudinal evaluation of risk factors for future diagnosis of that illness.

The American Heart Association (AHA) and the American Diabetes Association (ADA) have each published guidelines for cardiovascular disease prevention: The ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. This statement will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which AHA and ADA recommendations differ.

In this Review, Kathryn Taubert, Nathaniel Clark and Robert Smith explore the common features and risks of cardiovascular disease, cancer and diabetes—disease which together are responsible for more than 25 million deaths in the world each year. They examine the important role of cardiology health-care providers with regards to risks for other chronic conditions and occult disease. Collectively, cardiovascular disease, cancer and diabetes are responsible for more than 25 million deaths in the world each year, and millions more live with one or more of these diseases. Much of this disease burden could be prevented, however, by controlling the modifiable risk factors. Although this Review focuses primarily on health-care providers caring for patients with cardiovascular disease, we stress the importance of considering the totality of patients' health. We discuss the common features and risks of cardiovascular disease, cancer and diabetes, and how best to implement practices aimed at prevention. The shared risk factors of tobacco use, physical inactivity, overweight and obesity, and poor nutrition, and their management are discussed. General risk-factor screening recommendations are also outlined and specific screening strategies for the disease states are given. Finally, we discuss the appropriate role of cardiology health-care providers with respect to risks for other chronic conditions and occult disease.

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the inpatient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two thirds of all deaths in the United States and about $700 billion in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity—the major risk factors for these diseases—and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the ACS, ADA, and AHA review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment. ( Stroke . 2004;35:1999-2010)

Editor’s comment : The commentary by Dr. Grajower has such important clinical relevance that responses were invited from the three pharmaceutical companies that supply insulin in the U.S. and the American Diabetes Association, and all of these combined in this commentary. The commenting letter and individual responses were authored separately and are completely independent of each other. Diabetic patients treated with insulin, whether for type 1 or type 2 diabetes, are prone to often unexplained swings in their blood glucose. These swings can vary from dangerously low to persistently high levels. Most diabetic patients, and most physicians, will adjust insulin regimens so as to avoid hypoglycemia at the expense of hyperglycemia. Among the “textbook” reasons for variable glucose responses to any given insulin regimen are 1 ) site of administration, 2 ) exercise, 3 ) bottles not adequately mixed before drawing the insulin (for NPH, Lente, or Ultralente), and 4 ) duration of treatment with insulin (1). A new insulin was marketed by Aventis Pharmaceuticals about 1 year ago, insulin glargine (Lantus). The manufacturer seemed to stress that patients not use a started bottle of this insulin for >28 days (2). Two patients of mine highlighted this point. L.K. is a 76-year-old woman with type 2 diabetes, diagnosed at 55 years of age, and treated with insulin since age 56. Her insulin regimen was changed to Lantus at night together with Novolog before meals. She monitors her blood glucose four times a day. She used a bottle of Lantus until it ran out; therefore, a bottle lasted for 2 months. Her recent HbA1c was 7.6%. I retrospectively analyzed her home glucose readings by averaging her fasting blood glucose levels for the first 15 days of a new bottle and the last 15 days of that same bottle. The results were 137 ± …

We appreciate Dr. Tseng’s letter (1), as it identifies an error in our 2006 stated HDL cholesterol goals (2), when expressed in SI units, and allows us to comment further on our recommendation regarding the use of statins in those with type 2 diabetes. Tseng is correct that the 2006 goals for HDL (2) should read 40 mg/dl (1.03 mmol/l) for men …

We thank Dr. Spitz (1) for his letter commenting on the Diabetes Physician Recognition Program (DPRP) criteria regarding HbA1c (A1C) levels. The DPRP criteria were changed in 2000 to coincide with those used in the Health Plan Employer Data and Information Set (HEDIS) program. More recently in 2004, a decision was made to include two measures for A1C, LDL, and blood pressure. In the case of LDL, the change reflected the HEDIS measure, National Cholesterol Education Program guidelines, and the American Diabetes Association recommendation. In the case of A1C and blood pressure, changes were based on current American Diabetes Association recommendations. Using two measures (which some refer to as good and poor control) allows a more comprehensive assessment …

We would like to thank Dr. Power for his letter (1) and allowing us to comment on the appropriateness of the title for our clinical practice guidelines, the evidence levels used in our guidelines, and specifically our recommendation regarding screening for type 2 diabetes (2). The title “Standards of Medical Care in Diabetes” was chosen because in the view of the American Diabetes Association (ADA), the recommendations represent what we consider the “standards” for the care of patients with diabetes. We see a need to define these so that providers have a guide …