SOC 3 Flashcards
Goals of dpp
7% weight loss (max prevention at 10%) 150 minutes moderate intensity PA Lose 1-2 lbs/week to meet goals within first 6 months 500-1000 kcal deficit start with reducing fat intake
3, 10,15 year outcome of DPP program
3- 58% reduction
10- 1/3 reduction
15- 1/4 reduction
PA goals of DPP
150 minutes/week MIPA; PA expenditure of 700 kcals/week
similar to brisk walking
minimum 3x/week- avoid more than 2 days without exercise
minimum duration- 10 minutes
up to 75 minutes of strength training will be counted toward 160 minutes
What was the structure of the DPP program?
Phase 1: Structured core curriculum:
1st 16 sessions in 25 weeks were individual
topics: lower kcal, increase PA, SM, healthy behaviors, psychological/social/motivational changes
Phase 2: flexible maintenance
- individual or group
motivational campaigns
re-start opportunities
How can you measure diet quality?
Healthy Eating Index
Alternative Healthy Eating Index
DASH score
Name a few of many dietary approaches that are appropriate
Mediterranean
Low kcal
Low fat
What are additional alternatives to weight loss?
Prescription weight loss meds
Bariatric surgery
Why is physical activity important for peds and adults?
Improves insulin sensitivity
reduces abdominal fat
Interrupted periods of prolonged sitting may benefit _______
post prandial BG
In the immediate years after quitting smoking the risk of DM is higher or lower?
higher
CDC diabetes prevention recognition program
certifies technology assisted DPP modalities
- approved curriculums
- interaction w/ coach
- active participation
- physical activity reporting
- weight loss outcomes reported
How can delivery of DPP programs be reduced in cost?
- community settings vs. primary care offices
- group vs individual
- use lay health workers
National DPP
- in community settings (not medical settings)
- eligibility: overweight BMI, preDM labs w/in last year
Who should be offered Metformin?
- hx GDM
- BMI >/= 35
- <60 years old
Who should be considered for MEtformin?
All preDM
What is more effective metformin or ILI
ILI
Who should be offered DSMES?
All PWD
4 critical times for DSMES
@ dx
annually to assess ed, NTR, emotional factors
when complications arise
when transition in care occurs
what does DSMES do
provides knowledge, support, decision making and skill development
objectives of DSMES
- support informed decision making
- self-care behavior
- problem solving
- collaboration w/ care team
- must be cost effective
- patient centered
Inclusive language
instead of diabetic, control, test
PWD
Manage
Check
When will medicare reimburse DSMES?
- meets national standards
- recognized by ADA or other approving body
When is DSMES covered by insurance?
- when it’s done in person
- may not be covered virtual or over the phone
MNT may be covered by medicare part B
3 hours initial during 1st consult year, 2 hours of follow-up in subsequent years
DSME coverage by medicare
- 1 hour individual assessment
- 9 hour group (1x in lifetime)
- 2 hour follow-up annually
MNT effectiveness for T1DM
1-1.9% reduction A1c
MNT effectiveness for T2DM
0.3-2% T2DM
Goals of MNT for adults:
- achieve and maintain healthy BW
- attain individualized BP, BG, lipid goals
- delay or prevent onset of DM complications
Things RD should assess
- take into consideration pt preference, cultural background, health literacy
- healthcare access
- willingness and ability to make changes
- addressing barriers to change
- maintain pleasure of eating
- develop healthy eating pattern
Weight loss for T2DM
- improve A1c
- reduce CVD risk factors
- encourage reduced kcals, physical activity
modest weight loss benefits
- delay progression of pre-DM to T2DM
- benefit MGMT/tx T2DM
pre-DM WL goal
7-10%
T2DM WL goal
5% however 10-15% may be appropriate
Weight loss maintenance
kept it off for 5 years;associated w/ improved A1c and lipids
various plans work for weight loss
Structured low kcal meal plan
mediterranean style
low CHO
instead of diet rx
individualized meal plans
nutrient dense food
Who should not be on low CHO diet?
pregnant or lactating women
kids
PW renal dz
those with disordered eating
Dietary recommendations for CHO
- choose veggies, legumes, fruit, dairy, whole grains
- discourage SSB, processed foods/refined grains/added sugars
Dietary recommendations for those on insulin
insulin:CHO ratio for meal planning, modify insulin from meal to meal to improve glycemic management
protein recommendation for CKD
0.8-1 g/kg
Fat recommendations
avoid trans fats
quality>quantity
limit SFA
omega3 supplement
- did not improve glycemic mgmt in DM
- not recommended for prevention of CVD
What are naturally occurring omega-3 foods?
salmon, tuna, mackerel, herring, chia, flax, walnuts, canola oil, soybean oil
sodium
<2,300 mg in DM
<1,500 not recommended
Considerations for sodium
- palatability
- availability
- affordability
- difficulty meeting low sodium guidelines
Metformin and B12
consider periodic testing in those taking it LT
supplements not advised
cinnamon, curcumin, vitamin D, aloe vera, chromium, Vits E/C/carotene
Who needs a MVI?
- pregnant or lactating women
- older adults
- vegetarians
- low kcal or low CHO diet
What are the risks of alcohol?
weight gain
hypo and delayed hypo
hyper
what should you tell a PWD who wants to drink
risks, monitor BG after drinking to prevent or ID low
what are the alcohol recommendations?
women- 1/day or less
men- 2/day or less
5 ounce wine, 12 ounce beer, 1.5 ounce distill spirits
artificial sweeteners
- do not appear to affect BG management
best beverage choice
water; reduce intake of sugar sweetened and non-nutritive sweetened beverages
What did the Finnish prevention program find?
45% decreased transmission to DM x 7 years
Da Quinn DPP findings
40% decrease conversion to T2D x 30 years
Decrease all cause mortality;CVD mortality; micro vascular complications
Name 3 DPP programs
US DPP ,Finnish, Da Qing
Why is PA important for women planning pregnancy or already pregnant
May prevent GDM
Met firm in may be cost saving over what year period
10
Women with previous GDM given metformin in or ILI had what reduction in DM and for how many years
50%, 10 years
When BMI is >= 35, what is more effective metformin or ILI
Equally effective if under 60
What score on ADA DM risk test warrants testing
5 or higher
What questions are on ADA risk test
Age- up to 3 points Gender Hx GDM 1st degree relative with DM HTN Physical activity or lack of Weight status- up to 3 points
Why should third party payers cover DPP
Cost effective
Improve Outcomes
Maximal prevention of T2DM in those with preDM
10% weight loss
Why is reducing prolonged periods of sedentary time important
May reduce post prandial BG
When did Medicare reimbursement expand for DPP
2018
For whom was metformin most effective after 15 years
Hx GDM and with higher FPG > 110
Who should receive DSMES
All PWD
What % PWD on Medicare get DSMES
5-7%
What are 4 critical times for DSMES
when not meeting targets
When complicating factors arise
Transition in life and care
DSMES should be
Pt centered
Group or individual
May use technology
Should be communicated with whole care team
What does DSMES do
Improve knowledge skills decision making
Self care behavior
Problem solving
Collaboration with HC team
Outcomes of DSMES
Improve dm knowledge Improve self care behaviors Lower self reported weight Improve QOL Reduce all cause mortality risk Healthy coping Reduce HC costs
Gold star dsmes
6-10 H over 6-12 months Ongoing support Culturally and age appropriate Tailed to individual needs Behavioral strategies Address psychosocial issues Group or individual
Technology based DSMES gold star
2 way communication
Individualized feedback
Education
Pt generated health data used
Outcomes of DSMES
Reduce mortality
Reduce A1C by 0.57%
When will Medicare reimburse DSMES
Meets national standards
Recognized by ADA or ADCES
When done in person
When may low or very low cho diet be appropriate
Not meeting glycemic targets.
Pt declines meds
May be most effective for 6 months
<26% energy from cho
Most PWD report cho intake of
45%
Fiber associated with
Lower all cause mortality in pwd
Reduced risk of T2DM
Delayed hyper can occur when with HF or high PRO meals
3 H after eating
May need increase meal time bonus insulin
pRo of what % may increase satiety
20-30%
Do not replace saturated fat with
Refined CHO
Reduce it trial
4 g pure EPA reduce risk of averse CV event
5% reduction in those with ASCVD already on statin but still with high TG
Risk for delayed hypo after alcohol
Insulin or insulin secretgogues
Who meets PA guidelines
45% W/c and B/AA
65% H/L
Risk of PA with autonomic neuropathy
Decrease cardiac responsiveness
Postural hypotension
Impaired thermoregulation
Hypo risk
Prediabetic neuropathy
Improve outcomes with 150 minutes of MI PA
Reduce risk of feet ulcers or reulceration by
Wearing proper footwear
Moderate intensity PA
Examine feet daily
Foot injury or open sore
Non weight bearing exercise only
Does weight gain after smoking cessation undo CVD benefit
No
How does smoking cessation benefit pwd
Reduce BP reduce albuminuria
Psychosocial tx effect on A1C
Decrease 0,3%
How common is depression in pwd
1/4
More common in women
What med can help bulimic symptoms
GLP1 reduces hunger
When to monitor A1C after starting second generation atypical anti psychotics
4 months after starting then at least annually
