Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 3:

Prevention and Risk Reduction

Marjorie Cypress, PhD, MSN, ANP-BC, CDE,1 and Donna Tomky, MSN, ANP-BC, CDE, FAADE1

1Adult nurse practitioners and certified diabetes educators in Albuquerque, NM.

The importance of reducing risks of developing type 2 diabetes (T2D) cannot be overemphasized. The cost of diabetes and comorbidities continues to grow, with 2012 data indicating a cost of $245 billion, up from $174 billion in 2007.1 The most current estimates of the economic burden associated with diagnosed diabetes, undiagnosed diabetes, gestational diabetes, and prediabetes were in excess of $322 billion in 2012. This estimate included $244 billion in excess medical cost and $78 billion in reduced productivity.2

As the prevalence of diabetes continues to grow, some 86 million people in the U.S. over the age of 21 years have prediabetes.3 One in three people are forecasted to have diabetes by 2030.4 Prevention and risk reduction include not only reducing the risk for developing diabetes, but also preventing the vascular diseases associated with diabetes. Primary and secondary prevention of diabetes and its complications should be a focus of all health-care professionals. Interventions to recognize high-risk individuals and strategies to decrease risk should be considered an essential part of medical and nursing care.

PRIMARY PREVENTION OF DIABETES

Type 1 Diabetes

Many of the studies to prevent or delay type 1 diabetes (T1D) have focused on preserving β-cell function. These studies have used a number of immune intervention strategies, have been largely unsuccessful, and are not ready for routine clinical use. These active trials, however, are recruiting relatives of individuals with T1D and should be directed to TrialNet (http://www.diabetestrialnet.org) so they can be screened.

Type 2 Diabetes

Large-scale prospective randomized trials focused on the prevention of T2D have demonstrated that T2D can be either prevented or delayed in a population of people identified to have increased risk of diabetes because of impaired glucose tolerance. These prevention interventions are centered on lifestyle interventions that included diet and exercise. The six major trials—U.S. Diabetes Prevention Program (USDPP), Finnish Diabetes Prevention Study, Da Qing China, Swedish Malmö, Indian Diabetes Prevention Program, and Japan Prevention Trials—all have shown that lifestyle was more effective than controls in reducing the risk of developing diabetes (ranges from 42% to 58%).5–10 The largest of these was the 27 sites in the U.S. and Canada. The USDPP randomly assigned 3,234 participants ages 25–85 years to an intensive lifestyle intervention consisting of a weight-loss diet and 150 min of exercise a week, a medication intervention group (metformin), or a control group. The goal was to lose 5–7% body weight and to maintain at least 150 min of exercise a week. The results showed that individuals in the lifestyle intervention group, whose sustained average weight loss was ~5% of body weight and exercised averaged >150 min/week, had a 58% decrease in the risk for developing T2D. Individuals in the metformin group experienced a 31% decrease in the risk for developing T2D. The lifestyle group was most successful in decreasing the risk of developing diabetes in the population >60 years of age. Of note, 45% of the study population was from high-risk minority groups. This and other studies have provided the evidence for preventing T2D.

Since the USDPP, considerable research has translated the USDPP protocol to different settings, including hospitals, primary care, YMCAs, and work or church groups for at-risk adults for T2D, with promising results. Health coaches have been trained to deliver the 16-week curriculum and have produced positive results.11,12 The 16-week curriculum for the DPP is readily available online.13 The Centers for Disease Prevention and Control has instituted the National Diabetes Prevention Program (NDPP), which offers a recognition program known as the Diabetes Prevention Recognition Program (DPRP). The purpose of the DPRP is to recognize programs that have demonstrated effective delivery of a lifestyle change program (lifestyle program) to prevent T2D. The key objectives are to ensure the quality, consistency, and broad dissemination of the lifestyle intervention; develop and maintain a registry of organizations recognized for their ability to deliver an effective lifestyle program to people at high risk for T2D; and provide technical assistance to organizations that have applied for recognition to help them deliver an effective lifestyle program and achieve and maintain recognition status.13

All individuals with prediabetes should be referred to a diabetes prevention program (preferably the NDPP) and, equally important, to an ongoing effective support program. Nurses should be familiar with available community resources for diabetes prevention programs and refer at-risk patients to those interventions. At this time, not all health insurance plans cover these programs; however, some programs have received grant funding and are able to offer participants curriculum for free or at a reduced price. At $1,600 per quality-of-life years, the American Diabetes Association (the Association) has reviewed these intensive lifestyle interventions for diabetes prevention and has deemed them to be very cost effective.14 In 2016, the Centers for Medicare and Medicaid Services (CMS) proposed expanded Medicare reimbursement coverage for USDPP programs to expand preventive services using a cost-effective model.

Numerous studies have focused on diabetes medications (i.e., metformin, thiazolidediones, α-gluocosidase inhibitors, insulin secretagogues) to prevent T2D and have shown some effectiveness. Currently, however, no medications for diabetes prevention have approval from the U.S. Food and Drug Administration (FDA).

Other contributing risk factors for T2D and prediabetes are believed to be socioecological factors. The increased consumption of high-caloric fast food and soft drinks, larger food portion sizes, and a sedentary population (only 19% of adults are meeting physical activity guidelines) are cited for the increasing prevalence of obesity in adults and youth. In addition, low socioeconomic status, decreased access to health care, the lack of safe areas conducive to walking or exercising, and food deserts with very limited access to fresh produce all increase risk for diabetes and prediabetes.15

Identifying High-Risk Individuals

Adults and children of any age who are overweight or obese and have additional risk factors should be tested for diabetes or prediabetes (for diagnostic criteria, see Chapter 2, Diagnosis and Classification).11,16

People with obstructive sleep apnea have been found to be 2.5 times more likely to develop T2D than people without sleep apnea.17 Evidence shows that the intermittent shortage of oxygen in the body from sleep apnea may cause a stress response that can alter glucose metabolism and may play a role in insulin resistance. In addition, sleep apnea has been associated with hypertension and heart failure and may be an independent risk factor for the development of hypertension. The International Diabetes Federation (IDF) has suggested further testing on people who have symptoms of sleep apnea (witnessed apnea, heavy snoring, or daytime sleepiness).18 The treatment includes weight reduction (if overweight), decreased alcohol intake, and use of continuous positive airway pressure (CPAP). In addition, because metabolic diseases, including T2D, are common in patients with sleep apnea, the IDF recommends that these individuals be screened for other metabolic abnormalities.

Community blood glucose screening often is offered at health fairs and shopping malls, but it is difficult to evaluate and is subject to wide variability and inaccuracies. Its cost effectiveness, sensitivity, and specificity have been challenged,19,20 and this type of screening is not recommended. However, community screening in the form of risk factor assessment to identify individuals who have multiple risk factors for developing T2D and cardiovascular disease (CVD) may be beneficial. Community risk factor screening also can provide opportunities to heighten awareness of diabetes, identify high-risk individuals and refer them for appropriate testing, and promote early intervention or prevention strategies. It is therefore important that screening be conducted by a health professional with specific plans and referrals for people with and without regular medical care who have clear risk factors. The diabetes risk test is an online risk assessment program that anyone can access. It also directs the user to additional resources.21

Lifestyle Interventions

One of the most important lifestyle interventions for diabetes prevention focuses on healthful eating, maintenance of a desirable body weight, and regular, routine physical activity. Medical nutrition therapy and physical activity are effective in helping people lower their risks for developing diabetes, hypertension, dyslipidemia, and heart disease. Although high-risk adults with lifestyle interventions have shown a decreased risk of developing T2D, studies of adolescents have been problematic, with high dropout rates and difficulties with medication adherence.22

Medical nutrition therapy should focus on decreasing total calories as well as the intake of fat, particularly trans fat and saturated fat, and increasing the intake of whole grains and dietary fiber (see Chapter 4, Nutrition Therapy). It is important to incorporate individual circumstances, health status, preferences, and cultural and ethnic considerations.17 The most recent nutrition therapy recommendations for adults with diabetes state that there is no optimal macronutrient intake to support a reduction in excess body weight, and the literature does not provide support that one approach to decrease excess body weight is better than another. Instead, the recommendations emphasize a spectrum of eating patterns that result in reduced caloric intake. A weight loss of >6 kg (approximately a 7–8.5% loss of initial body weight), regular physical activity, and frequent contact with RDs appears important for consistent beneficial effects of weight loss.23

Physical activity should be encouraged universally. The Joint Statement by the American College of Sports Medicine and the Association reports evidence that at least 2.5 h/week of moderate to vigorous physical activity should be undertaken as part of lifestyle changes to prevent T2D onset in high-risk adults.24 The CDC, the American College of Sports Medicine, and Healthy People 2020 all recommend moderate-intensity physical activity (like walking) for a minimum of 150 min/week, 30 min/day for 5 days a week, or vigorous-intensity physical activity for 75 min/week. Also recommended is resistance training ≥2 times a week. Evidence shows that this combination may decrease A1C, help prevent the onset of incident diabetes, and help decrease risks of CVD.

Starting to exercise or increasing physical activity to 20 or 30 min/day initially may be too difficult a goal. Advise sedentary people to begin increasing their physical activity gradually. Walking for 10 min several times a day may be easier for some people than trying to walk for 30–40 min at a time. Exercise can include a variety of activities, such as walking instead of driving, playing with children or grandchildren, gardening, cleaning house, playing tennis, biking, or swimming. Assessing individual preferences, physical ability, and safety is important when choosing the type of exercise. Stress the importance of adequate hydration while doing any type of physical activity. The most recent recommendations from the Association indicate that all individuals, including those with T2D, should be encouraged to limit the amount of time they spend sitting; prolonged sitting should be interrupted at least every 30 min for blood glucose benefits (see resources at www.healthypeople.gov).16

Along with high-risk factors, stress can increase the risk for glucose intolerance in susceptible individuals. Stress hormones such as cortisol and catecholamines that are secreted during periods of stress can alter glucose metabolism. Depression also is associated with T2D and is believed to be bidirectional. Although depression can affect the person with diabetes, it may be that depression also can increase the risk of developing T2D.25 The PHQ-9 is a depression scale that is easily and quickly administered and can help quantify the severity of symptoms, perhaps prompting early treatment.26 Nurses should be aware of the high prevalence and associations between depression and diabetes and should understand the importance of counseling or medications to help control symptoms of stress and depression. It is also important to assess a person’s support network of friends, family, church, community, or other avenues that may help in coping.

Changing behavior or maintaining healthy behaviors is challenging. People need to be ready to change and to view these lifestyle behaviors as important. Assessment must include readiness to change, how behavior change or health is valued, and one’s confidence and ability in oneself to be successful.

Because it is well known that lifestyle changes can decrease the risk for developing T2D, improve lipids, improve blood pressure, lower weight, and generally decrease risk for cardiovascular events, identifying high-risk individuals and intervening with prevention strategies is of utmost importance (Table 3.1). Screening, counseling, monitoring, and perhaps initiating drug therapy may be indicated.

Table 3.1—Recommendations for Preventing or Delaying Diabetes

• Educate individuals about the benefits of modest weight loss and regular physical activity.

—Medical nutrition therapy (MNT ): Reduce fat, especially saturated fat (<7% of calories); increase dietary fiber; control calories.

—Physical activity: Perform 30 min/day of moderate-intensity exercise or activity, 5–7 days a week.

—Follow-up: Refer to a registered dietitian for MNT education and follow-up.

• Screen high-risk individuals with risk factors, including BMI >25 kg/m2, family history of diabetes or early cardiovascular disease, high-risk ethnic group, history of gestational diabetes mellitus or delivery of baby ≥9 lb, or history of impaired glucose tolerance or glycosuria.

—If normal, re-screen at 3-year intervals, or more frequently if indicated.

—If abnormal, confirm test on another day.

• Assess for other cardiovascular risk factors.

—Encourage smoking cessation.

—Control blood pressure.

—Manage lipid levels.

—Control hyperglycemia.

• Recommend or refer for appropriate treatment, for example, smoking cessation program, primary care provider for control of hypertension and dyslipidemia, dietitian, certified diabetes educator, exercise physiologist, community resources, or mental health specialist.

• Consider drug therapy for diabetes prevention (metformin), and evaluate for aspirin therapy (e.g., high risk for CVD) in some individuals.

Cardiometabolic Risk

Many people both with and without T2D have a constellation of risk factors that predispose them to CVD. These include being overweight or obese (BMI ≥25 kg/m2, BMI ≥23 kg/m2 in Asian Americans); having hypertension, dyslipidemia (high triglyceride and low [high-density lipoprotein] cholesterol levels), hyperinsulinemia, insulin resistance, family history, or albuminuria; and smoking (Figure 3.1).

Figure 3.1—Cardiometabolic risk factors

Figure 3.1—Cardiometabolic risk factors

Source: From the American Diabetes Association.27

People with diabetes are at risk for chronic microvascular and macrovascular complications. Lowering A1C to approximately <7% has been shown to decrease the risk of microvascular complications, and if implemented soon after diagnosis, it is associated with a long-term reduction in macrovascular disease.16 A large percentage of people with diabetes, however, will develop and may die from CVD.28

DIABETES AND CARDIOVASCULAR DISEASE PREVENTION STRATEGIES

Cardiovascular disease prevention strategies also can be divided into primary and secondary prevention. In individuals who already have been diagnosed with diabetes, strategies should be aimed at preventing CVD and other complications of diabetes. In individuals with prediabetes, with cardiometabolic risk factors, or at high risk for developing T2D, the focus is on preventing the onset of diabetes and treating cardiovascular risk factors (Table 3.1). Treating cardiovascular risk factors, such as hypertension and dyslipidemia; avoiding smoking; and preventing the development of T2D in patients with impaired glucose tolerance may lead to decreased morbidity and mortality from CVD.29

Smoking Cessation

Smoking is a risk factor for the development of diabetes and prediabetes because it is associated with insulin resistance, increased abdominal fat distribution, dyslipidemia, and hypertension.30–33 Cigarette smoking and diabetes markedly increase the risk not only for macrovascular disease but also for diabetes-related microvascular disease.28 The risks of smoking may be well known, but it is important that health-care providers continue to urge individuals who smoke to stop and to educate people who do smoke about the increased risks of CVD and other diabetes complications. All smokers should be asked about their readiness to stop smoking and should be referred to smoking cessation programs. Assessing smoking status and readiness to change is important in the approach to smoking cessation. Maryland’s Tobacco Resource Center offers more in-depth advice to health-care professionals (http://mdquit.org/cessation-programs/brief-interventions).

It may be advantageous to combine the medication varenicline or bupropion with a cessation program. In addition, nurses and other health-care providers should advise all individuals with diabetes or risk factors for diabetes and vascular diseases not to start smoking. E-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation.

Hyperglycemia

Recommendations for the treatment for people with prediabetes (impaired fasting glucose or impaired glucose tolerance, or A1C level) are to prevent the development of T2D with intensive lifestyle modification. For individuals with particular characteristics (see Table 3.2), the initial treatment may be metformin,34 which has been shown to decrease the risk of progression from prediabetes to diabetes. Lowering glycemic levels to near normal ranges with A1C <7.0% soon after diagnosis can reduce the long-term risk for micro- and macrovascular complications. More stringent A1C goals of <6.5% might be reasonable for selected individuals without significant hypoglycemia, and with a long life expectancy and no significant CVD.16,35 In patients with T2D, lifestyle modification and metformin treatment are recommended at diagnosis (see Chapter 7, Therapy for Type 2 Diabetes).16 Targets for glycemic control are A1C <7% in people with diabetes (80–130 mg/dL preprandial [3.9–7 mmol/L] and <180 mg/dL postprandial [<10 mmol/L], both capillary blood glucose) and A1C in the normal range (4–5.5%) for diabetes prevention.16 Goals should be individualized based on duration of diabetes, age and life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

Table 3.2—Treatment Recommendation for Individuals with Prediabetes

Population

Treatment

Impaired fasting glucose or impaired glucose tolerance or A1C 5.7–6.4%

Lifestyle modification (i.e., 5–10% weight loss and moderate-intensity physical activity ~30 min/day)

Individuals with prediabetes and any one of the following:

• <60 years of age

• BMI ≥35 kg/m2

• Rising A1C despite lifestyle intervention

• Prior gestational diabetes mellitus

Lifestyle modification (as above) or metformin (850 mg/twice a day)

Metabolic Surgery

There is strong and consistent evidence that managing obesity can delay the progression from prediabetes to type 2 diabetes. In addition, numerous trials also have evidence of reduction of cardiovascular risk factors. Some studies have shown remission of T2D in those who have undergone metabolic surgery.36,37 Complete remission is a return to “normal” measures of glucose metabolism (A1C in the normal range, fasting glucose <100 mg/dL [5.6 mmol/L]) of at least 1 year’s duration in the absence of active pharmacologic therapy or ongoing procedures.38 According to the 2017 ADA standards of care metabolic surgery should be recommended in adults with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans), and in adults with BMI 35.0–39.9 kg/m2 (BMI 32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy. Metabolic surgery should be considered for adults with T2D with BMI 30–34.9 kg/m2 (BMI 27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite lifestyle and optimal medical control by either oral or injectable medications including insulin. Patients with T2D who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring.16

Hypertension

Blood pressure should be measured at every routine visit. The goal for managing hypertension in diabetes is a blood pressure <140/90 mmHg. Lower systolic and diastolic blood pressure targets such as <130/80 mmHg may be appropriate for those at high risk of CVD to provide further renal protection or reduced stroke risk, if goals are achieved without undue treatment burden.16 Patients with confirmed blood pressure >140/90 mmHg (in the office) should in addition to lifestyle management have prompt initiation and timely titration of pharmacologic therapy to achieve the blood pressure goals. Initial medications include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, and dihydropyridine calcium channel blockers, which have been demonstrated to lower the risk of cardiovascular events in people with diabetes.39Because of the potential alteration in potassium and creatinine level when using ACE, ARBs, or diuretics, these levels should be monitored. Also be aware that ARBs and ACE inhibitors are contraindicated in pregnancy because they may cause fetal damage. Most people generally will require two or more medications to control blood pressure in the target range. In addition to ACE, ARBs, and diuretics, calcium channel blockers or β-blockers may be added. Nighttime dosing of at least one antihypertensive medication may be considered (see Chapter 10, Cardiovascular Complications).

Dyslipidemia

Abnormal lipids are prevalent in patients with T2D, contributing to a very high risk of CVD. It is reasonable to obtain a lipid profile in individuals with diabetes, with treatment based on lipid levels and other risk factors, including age, family history, smoking, blood pressure, chronic kidney disease (CKD), albuminuria, and presence of CVD. Lipid screening may be considered at the diagnosis of diabetes, at an initial medical evaluation and every 5 years thereafter, or more frequently if indicated.16 The Association recommends the use of statin therapy in addition to lifestyle therapy in all individuals with diabetes and atherosclerotic cardiovascular disease risk factors. Statin dosage is based on cardiovascular risk factors (e.g., family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria (see Table 3.3 and Chapter 10, Cardiovascular Complications).

Table 3.3—Recommendations for Statin Treatment in People with Diabetes

Table 3.3—Recommendations for Statin Treatment in People with Diabetes

* In addition to lifestyle therapy.

** ASCVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

Goals are no longer based on LDL cholesterol but instead are based on cardiovascular risk factors or overt CVD. Recommendations to intensify lifestyle therapy and optimize glycemic control are made for those with elevated triglyceride levels (>150 mg/dL) or low HDL cholesterol (<40 mg/dL in men and <50 mg/dL in women). An evaluation for secondary causes or medication to prevent pancreatitis is recommended for patients with triglycerides >500 mg/dL. Lifestyle measures, including low trans fat, high-fiber diet, weight loss (if indicated), smoking cessation, and physical activity are recommended to improve the lipid profile in patients with diabetes. Cholesterol testing may be helpful to monitor adherence to therapy. Combination statin and fibrates or statin and niacin has not been shown to provide additional cardiovascular benefit over the use of statin therapy alone and generally is not recommended. Statin therapy is contraindicated in pregnancy.

Little evidence supports the treatment of individuals with T1D with a statin, but this treatment should be considered if the individual demonstrates increased cardiovascular risk factors.

Albuminuria

Albuminuria, which is defined as an urinary albumin-to-creatinine ratio (UACR) of ≥30 mg/g creatinine, is a marker for cardiovascular risk as well as renal disease. All individuals with diabetes should be screened annually, starting 5 years after diagnosis of T1D and upon diagnosis of T2D. Good glycemic control and management of hypertension with ACE inhibitors or ARBs and other drugs as necessary can slow the progression of diabetic kidney disease (see Chapter 13, Diabetic Nephropathy and End-Stage Renal Disease). Blood pressure control also has been shown to decrease cardiovascular events in people with diabetes. Albuminuria along with estimated glomerular filtration rate (eGFR) levels may be used to stage CKD. Nurses should recognize that exercise within 24 h of testing, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values.

Aspirin and Antiplatelet Therapy

Evidence indicates that aspirin therapy can reduce the risk of cardiovascular events in high-risk individuals with previous MI or stroke (secondary prevention). The net benefit in primary prevention with no prior cardiac events in individuals with or without a diagnosis of diabetes is unclear. The Association recommends aspirin therapy (75–162 mg/day) as secondary prevention in those with diabetes and a history of atherosclerotic CVD. For those with atherosclerotic CVD and documented allergy to ASA, clopidogrel (75 mg/day) is recommended. The ADA recommendation for primary prevention is to consider ASA therapy (75 mg–162 mg) in those with T1D or T2D who are at increased cardiovascular risk (10-year risk >10%).16 This includes most men or women ≥50 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).16

Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (e.g., women <60 years of age with no major additional CVD risk factors), because the potential for adverse effects from bleeding likely offset the potential benefits.

In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5–10%), clinical judgment is required. Aspirin therapy (75–162 mg/day) can be used as a secondary prevention strategy in individuals with diabetes who also have a history of CVD. In individuals who have a documented aspirin allergy, then clopidogrel (75 mg/day) should be used. Dual antiplatelet therapy is reasonable for up to a year after an acute coronary syndrome.

Alcohol

Nurses should carefully assess alcohol consumption and counsel patients on the dangers of excessive alcohol intake. Aside from being high in calories, stimulating appetite, and perhaps being contraindicated with certain medications, excessive alcohol consumption is associated with other social and health problems. If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues (i.e., sulfonylureas). Education and awareness regarding the recognition and management of delayed hypoglycemia is warranted.

Immunizations

Individuals with diabetes, especially those with vascular complications, are at high risk for morbidity and mortality associated with influenza and pneumococcal disease. Patient education regarding the need for vaccinations is necessary. Routine vaccinations for children and adults with diabetes should be provided according to age-related recommendations. Individuals with diabetes who are ≥6 months of age should receive an influenza vaccine every fall. A pneumococcal revaccination is recommended for individuals ≥65 years of age who were immunized when they were <65 years of age if the vaccine was administered >5 years ago. Revaccination may be advised in individuals with diabetes who suffer from renal disease or other immunocompromised states.11 Since those with T1D or T2D have higher rates of hepatitis B than the general population, the association recommends a 3-dose series of hepatitis B vaccine to those unvaccinated adults with diabetes aged 19–59 years, and consider in those ≥60 years of age. The Association endorses the CDC advisory panel recommendations that both pneumococcal conjugate vaccine 13 (PVC 13) and PPS v23 should be administered routinely in series to all adults ≥65.16 The full CDC recommendations are available online (www.cdc.gov/vaccines/schedules/hcp).

Periodic Medical Visits

It often is challenging to convince people who feel healthy to see their health-care providers for routine visits. Individuals with multiple risk factors, however, need regular evaluation and management. A person with a chronic illness may need to be seen three to four times a year. Health-care providers must emphasize the need for regular screening and evaluation not only in these individuals but in their family members as well. Identification of individuals at high risk for diabetes and cardiovascular disease may be accomplished effectively when patients come in accompanied by a family member who has obvious risk factors. Education of family members regarding the risks of developing T2D should be provided at that time, and those at-risk family members should be referred for further evaluation.

Individual health-care beliefs may present a barrier to preventive care if individuals at high risk do not perceive themselves as susceptible to illness. It is the duty of the health-care team to be cognizant of the health-care beliefs of the individuals they see. The health-care team should work together to identify, screen, and diagnose high-risk individuals so that early intervention strategies can be initiated.

Socioecological Perspective

A multifaceted approach is necessary to prevent diabetes, reduce risk, and promote health. It is important that nurses view the individual within the larger context of family, community, and society. This may include cultural traditions, food preferences, access to medical care, and social and community support, as well as resources, such as environments, conducive to health. These resources may include safe walking trails, access to healthy and fresh produce, healthier choices in vending machines, and physical education in the schools.

SUMMARY

Primary and secondary intervention is essential in the prevention of diabetes and the potential complications of diabetes. Interventions to recognize high-risk individuals and strategies to decrease the risk of diabetes and diabetes-related vascular complications should be considered an essential part of nursing care. Nurses are in an excellent position not only to counsel the individual patient but also to advise the family regarding risk factors and to counsel them on preventive strategies that may help lower incidence of diabetes and cardiovascular disease. Every January, the Association publishes the updated Standards of Medical Care in Diabetes based on the latest research findings and these standards may be accessed online.16

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