ADA Advanced Postgraduate Course

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Cultivating mindfulness in patients with diabetes is a useful self-help strategy to combat depression and foster healthy habits.

"How can you effectively manage yourself if you’re not aware of your self?" posited Dr. Laura Young at the annual advanced postgraduate course held by the American Diabetes Association.

One in four patients living with diabetes will develop depression in their lifetime, with 80% relapsing within 5 years of their depression going into remission, she said. Comorbid diabetes and depression increase mortality 2.5-fold, as well as raising the risk of all diabetes complications.

Mindfulness-based interventions teach individuals to be in the present moment, without judgment or emotional reactivity. The benefits are thought to be improved clarity, awareness, and acceptance.

Mindfulness also helps to weaken old, unhelpful, and automatic thinking habits that can potentially prevent positive action. This is critical for patients with diabetes, particularly those with type 1, who tend to go into autopilot when managing their disease, said Dr. Young, with the University of North Carolina in Durham.

"So many of our patients just get into a pattern of ‘It’s just what I’ve always done,’ " she said. "Mindfulness can help patients take a step back, evaluate those habits, and decide which are helping and which are not so great, and potentially change those habits."

Dr. Young recalled a recent patient who each evening had a bedtime snack that was sometimes healthful, but more often, not. The patient could offer no concrete reason for this snacking habit and admitted that 75% of the time he wasn’t even hungry.

"It hadn’t even occurred to him that it was something he shouldn’t be doing because it was something he’d always done," she said.

Mindfulness-based interventions have been studied for decades and have some of the best, most robust evidence behind them among self-help strategies, Dr. Young observed. In the Heidelberger Diabetes and Stress Study, patients with type 2 diabetes randomized to a mindfulness-based intervention had lower levels of depression, psychosocial distress, and improved health status over 5 years of follow-up compared with treatment-as-usual controls (Diabetes Care 2012;35:945-7).

A recent study found a mindful-eating intervention was as effective as a diabetes education self-management "Smart Choices" intervention in significantly improving depressive symptoms, cognitive control, and disinhibition of control regarding eating habits in adults, aged 35-65 years, with type 2 diabetes not on insulin therapy. Weight control at 3 months was also similar with either group-based intervention (Health Educ. Behav. 2014 April;41:145-54)

Mindfulness interventions have been readily adopted in some areas, often combined with yoga or cognitive-behavioral therapy, but these could be a hard sell for those who envision sitting cross-legged on yoga mats in the lotus position.

"I have a lot of patients from rural North Carolina, and they aren’t going to buy into that," Dr. Young said.

For these patients, her university offers a 2.5-hour class in which patients simply sit in a circle on chairs while being guided through mindfulness exercises. An ongoing study at the university is comparing this approach with a health education control group on physiological and psychological outcomes in patients with type 2 diabetes and high levels of diabetes-related distress, she said.

A show of hands at the meeting revealed that about a third of the audience is already using mindfulness training in their patients with diabetes. Dr. Young pointed out that the meeting host city of San Francisco had 386 therapists who use a combination of cognitive-behavioral therapy and mindfulness, whereas 40 therapists are available in Mississippi, as are a handful in rural North Carolina.

"So your patients can do this," she added.

Dr. Young reported research support paid to her university from numerous pharmaceutical firms and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Patients with diabetes have an increased incidence for a number of infections, but vaccine-preventable diseases need not be among them.

"In the risk/benefit category, there’s a lot of potential benefit to these" immunizations, Dr. David Parenti said at the annual advanced postgraduate course held by the American Diabetes Association.

Studies have shown that patients with diabetes who are aged 23-59 years have a twofold higher relative risk of acute hepatitis B virus, compared with those without diabetes. In addition, the diabetic case fatality rate is more than double, at about 5%.

Individual glucose monitoring has reduced the transmission of hepatitis B virus by contaminated medical equipment, but outbreaks still occur in a variety of settings because of lapses in infection control, said Dr. Parenti, professor of medicine at George Washington University, Washington.

©luiscar/Thinkstockphotos.com

Still, vaccination rates are no better among patients with diabetes than those without. From 1999-2004 to 2005-2008, vaccination rates inched up only slightly among diabetics for both hepatitis A (9.3% to 15.4%) and hepatitis B (15.2% to 22.4%), according to National Health and Nutrition Examination Surveys (Hepatology 2011;54:1167-78).

Indeed, a show of hands revealed that less than a dozen of the roughly 500 attendees at the meeting had vaccinated their patients.

"I do think hepatitis B vaccination is important, but the question is: How do you know whether it works and how do you monitor it?" Dr. Parenti said.

A variety of factors can impair the immunogenicity of the hepatitis B vaccine, including gluteal or intradermal administration, increased age, higher body mass index, and genetics, such as human leukocyte antigen-DR3, which is present in about 95% of people with type 1 diabetes.

Unpublished data from the Centers for Disease Control and Prevention suggest that diabetes patients experience a similar drop in seroprotection with age (80% at 41-59 years, 65% at 60-69 years, and less than 40% at 70 years and older), he noted.

For patients who fail to respond to the first or second series of vaccinations, based on postimmunization serologic testing, using a higher 40 mcg-dose or four doses at 0, 1, 2, and 6 months has been shown to improve immunologic responses. There is no need, however, to restart a series if it was interrupted, regardless of the duration between vaccinations, Dr. Parenti said.

Only about 15% of individuals receive the herpes zoster vaccination, approved for persons aged 50 years and older, despite a third of the population expected to develop shingles within their lifetime. The risk is nearly doubled among diabetics under age 49 years with a hemoglobin A_1c exceeding 8%, he said.

For those who do get vaccinated, however, a small Japanese study (J. Infect. 2013;67:215-9) reported similar humoral and cellular responses 3 and 6 months postvaccination among patients aged 60-70 years, with and without diabetes, he noted.

One attendee said that Medicare often refuses to cover herpes zoster and hepatitis vaccinations, leading her to remark, "It’s kind of turning into a class issue. My patients with money will get the vaccine."

It’s not just Medicare, but a significant number of other insurers who aren’t paying for the vaccines, particularly the pricey $300-$400 zoster vaccine, Dr. Parenti replied. Much depends on the patient’s plan. For example, the shingles vaccine is covered by Medicare Part D, but not Part A or Part B, while Medicare Part B covers recipients at "high or medium risk" for hepatitis B, including those with diabetes or end-stage renal disease. At this point, prior authorization is needed for all insurers, including Medicare, and appeals may be necessary, he said.

Dr. Parenti reported serving on a data safety monitoring board for the National Institute of Allergy and Infectious Diseases and receiving research support from Merck, Pfizer, Cubist Pharmaceuticals, Janssen Pharmaceuticals, Insight, and the National Institutes of Health.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

pwendling@frontlinemedcom.com