IHS
Standards of Care

Type 2 Diabetes
Summary

General Recommendations
for Care

Care/Test/Screening
  • Perform diabetes-focused visit
  • Review care plan: assess goals/strengths/barriers
  • Assess nutrition, physical activity, BMI, and growth in youth

Frequency
  • Every 3-6 months
  • Each diabetes visit, revise as needed
  • Each diabetes visit

Self-Management Education
(DSME)

Care/Test/Screening
  • Refer to diabetes educator

Frequency
  • At diabetes diagnosis, then every 6-12 mo., or more as needed

Medical Nutrition Therapy
(MNT)

Care/Test/Screening
  • Refer for MNT provided by a registered dietitian

Frequency
  • At diabetes diagnosis and at least yearly, or more as needed

Glycemic Control

Care/Test/Screening
  • Check A1C, individualize goal: e.g., < 7%, 7-8%, 8-9%, etc.
  • Review goals, medications, side effects
  • If prescribed, review SMBG data
Frequency
  • Every 3-6 months
  • Every diabetes visit
  • Every diabetes visit

CVD Risk Reduction

Care/Test/Screening
  • Prescribe statin with lifestyle therapy regardless of LDL level
  • Check lipid profile
  • Assess smoking/oral tobacco use
  • Aspirin therapy 75-162 mg/day (unless contraindicated)
  • Total cholesterol < 200 mg/dL
  • Triglycerides < 150 mg/dL
  • Non-HDL cholesterol < 130 mg/dL,< 100 mg/dL (for very high risk)
  • LDL < 100 mg/dL (optimal goal),
  • LDL < 70 mg/dL (for very high risk)

Frequency/Which Patients
  • Adults with CVD; age > 40 y. with >= 1 CVD risk factor
  • Annually. If abnormal, follow current NCEP guidelines.
  • Each visit: Ask, Advise, Assess, Assist, Arrange
  • Known CVD/PAD; 10-year CVD Risk > 10%

Blood Pressure

Care/Test/Screening
  • Check blood pressure
  • Individualize goal: e.g., < 130/80 mmHg, < 140/90 mmHg
  • Youth goal: Varies with age

Frequency
  • Every visit

Kidney Care

Care/Test/Screening
  • Check urine albumin/creatinine ratio (UACR) for albuminuria using a random urine sample (normal < 30 mg/g; micro 30-300 mg/g; macro > 300 mg/g)
  • Check serum creatinine and estimate GFR
  • If HTN, prescribe ACE Inhibitor or ARB unless contraindicated

Frequency
  • At diabetes diagnosis, then annually
  • At diabetes diagnosis, then annually

Eye Care

Care/Test/Screening
  • Retinal camera photo or dilated eye exam by an ophthalmologist or optometrist

Frequency
  • At diabetes diagnosis, then annually; or as directed by eye specialist

Foot Care

Care/Test/Screening
  • Visual inspection of feet with shoes and socks off
  • Perform comprehensive lower extremity/foot exam
  • Screen for PAD (consider ABI)

Frequency
  • Each diabetes visit; stress daily self-exam
  • At diabetes diagnosis, then annually
  • At diabetes diagnosis, then annually

Oral Care

Care/Test/Screening
  • Inspection of gums/teeth
  • Dental exam by dental professional

Frequency
  • At diabetes diagnosis, then at diabetes visits
  • At diabetes diagnosis, then every 6 -12 months

Autonomic Neuropathy

Care/Test/Screening
  • Assess CV symptoms; resting tachycardia, exercise intolerance, orthostatic hypotension
  • Assess GI symptoms; gastroparesis, constipation, diarrhea
  • Assess sexual health/function for men and women

Frequency
  • At diabetes diagnosis, then annually
  • At diabetes diagnosis, then annually
  • At diabetes diagnosis, then annually

Emotional Health

Care/Test/Screening
  • Assess emotional health; screen for depression, substance abuse

Frequency
  • At diabetes diagnosis, then annually

Immunizations

Care/Test/Screening
  • Influenza vaccine
  • Pneumococcal vaccine
  • Hepatitis B immunization

Frequency/Which Patients
  • Annually
  • Once < 65 y. Re-immunize if >= 65 y. and 1st dose given before age 65 and if vaccine was administered > 5 y. prior.
  • Unvaccinated adults < 60 y.

Preconception
Pregnancy
and Postpartum Care

Care/Test/Screening
  • Ask about reproductive intentions/assess contraception
  • Provide preconception counseling
  • Screen for undiagnosed type 2 diabetes
  • Screen for GDM in all women not known to have diabetes
  • Screen for type 2 diabetes in women who had GDM

Frequency/Which Patients
  • At diabetes diagnosis, and then every visit
  • 3-4 months prior to conception
  • At first prenatal visit
  • At 24-28 weeks gestation
  • At 6-12 weeks postpartum, then every 1-3 y. lifelong

IHS Division of Diabetes