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Diabetes is an independent risk factor for heart failure (HF), with current trends indicating that nearly half of patients with type 2 diabetes will develop this complication. The presence of diabetes also worsens the prognosis of those with HF; people with both conditions have nearly double the mortality rate of those with HF who do not have diabetes (1–3). Additional risk factors for the development of HF in people with diabetes include increasing age, longer duration of disease, insulin use, ischemic heart disease, peripheral artery disease, nephropathy, poor glycemic management, hypertension, obesity, and higher levels of N-terminal pro b-type natriuretic peptide (2,4,5). Recently, HF, including diabetic cardiomyopathy, has become a more well-recognized complication of diabetes, with a prevalence rivaling that of established cardiovascular disease (CVD). Clinical interest in the management of type 2 diabetes in the presence of HF has grown with the publication of cardiovascular outcomes trials (CVOTs) for sodium–glucose cotransporter 2 (SGLT2) inhibitors demonstrating HF-related benefits and other trials showing heightened risk with the use of certain other antihyperglycemic therapies. To understand the interrelatedness of diabetes and HF, it is important to understand the pathophysiology of HF in people with diabetes. Structural heart disease via cardiac ischemia and infarction, also known as ischemic cardiomyopathy, is a documented complication of hyperglycemia. Yet, ischemic events are not a requirement for the development of HF in people with diabetes. The presence of systolic or diastolic dysfunction in people with diabetes, in the absence of common causes such as coronary artery disease, hypertension, or valvular heart disease, is termed “diabetic cardiomyopathy” (5). The development of diabetic cardiomyopathy is multifactorial, with insulin resistance, changes in cellular metabolism, and hyperglycemia-induced advanced glycation end products triggering a cascade of deleterious effects that contribute to hypertrophy, fibrosis, autonomic dysfunction, and …

Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of incretin-based therapies for the management of hyperglycemia and, in some cases, cardiovascular risk in people with type 2 diabetes. These agents act on multiple physiological pathways involved in type 2 diabetes with the effect of increasing insulin secretion and decreasing glucagon to control glucose levels (1,2). They also transiently slow gastric emptying, reduce appetite, and facilitate weight loss and other metabolic improvements (3). Consensus recommendations from the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) and American Association of Clinical Endocrinologists/American College of Endocrinology advocate that GLP-1 receptor agonists, among other therapies, should be considered as a second-line treatment option in people with type 2 diabetes when glucose levels are not well controlled on metformin (4–6). Additionally, in patients with type 2 diabetes and atherosclerotic cardiovascular disease or chronic kidney disease, a GLP-1 receptor agonist or sodium–glucose cotransporter 2 (SGLT2) inhibitor with proven cardiovascular benefit is recommended as a first-line therapy for the reduction of cardiovascular risk (4–6). GLP-1 receptor agonists may also be used as a first-line treatment in those who cannot use metformin or when reduced renal function precludes metformin use (human-based GLP-1 receptor agonists only) (4–6). In particular, the recommendations favor GLP-1 receptor agonists and SGLT2 inhibitors because they have a low risk of hypoglycemia and promote weight loss (5). Several GLP-1 receptor agonists are available in the United States and worldwide, some of which are analogs of human GLP-1 (dulaglutide, liraglutide, and semaglutide), whereas others are exendin-based (exenatide and lixisenatide) (7–13). The GLP-1 receptor agonist albiglutide was also approved, but has been withdrawn for commercial reasons. Until recently, all GLP-1 receptor agonists were administered by subcutaneous injection, although a once-daily oral formulation …

Continuous glucose monitoring (CGM) technology has brought about a paradigm shift in defining glycemic control in diabetes management and research. A1C and blood glucose monitoring have been widely accepted measurements in diabetes care, yet each has limitations in its clinical utility. A1C is established as an indicator of population health and long-term risk for microvascular complications but is less useful in personalizing glycemic goals, guiding therapy changes, or understanding patterns of glycemic excursions (1). Furthermore, A1C has limitations in accuracy and reliability in the context of hemoglobinopathy, anemia, iron deficiency (2), pregnancy (3), and racial differences (4). With increasing evidence regarding the relationship of glycemic variability with micro- and macrovascular risks, the definition of diabetes “control” is changing, and that change is bringing opportunity to tailor therapy decisions that truly improve outcomes (5). Self-monitoring of blood glucose (SMBG) has been an important tool for calculating insulin doses and gaining an understanding of daily glucose patterns. SMBG provides the glucose level at a single point in time without the context of past or future directionality and carries a burden of pain and inconvenience for patients, further limiting the amount of data available to analyze (1). The accuracy of an SMBG reading is dependent on the user’s testing technique and on the accuracy of the glucose meter itself; many glucose meters do not meet accuracy standards (6). Although CGM provides a wealth of information that A1C testing and SMBG lack, adoption of and persistence with this technology have been limited (7). However, with the arrival of systems for personal use (real-time use for patients) and professional use (blinded for patients with retrospective analysis by clinicians) that are more affordable and user-friendly (i.e., that do not require SMBG calibration and are indicated as an alternative to SMBG for making treatment …

More than one in 10 Americans today are living with diabetes (1). To prevent acute and chronic complications of diabetes, including death, patients with diabetes often require multiple medications and medication management supplies to enable effective, safe, and evidence-based control of hyperglycemia. These include insulin and noninsulin medications, technologies for glucose monitoring, and equipment for administration of injectable medications (both insulin and noninsulin injectables). Management of hyperglycemia is increasingly expensive for patients and the health care system, having increased 240% from the period 2005–2007 to 2015–2017, from $16.9 billion to $57.6 billion annually (2). Although the majority of these costs are borne by public and private payers (2), patients and caregivers increasingly report cost-related distress, nonadherence, and adverse health outcomes stemming from the costs of managing their disease (3–5). It is therefore vital for primary care clinicians, who care for the majority of people with diabetes (6), to be cognizant of the financial impact of diabetes management on their patients and to reduce it as much as possible. Insulin is just one component of comprehensive diabetes care, but it is the most critical for people who require it to live (i.e., people with type 1 diabetes and some with longstanding type 2 diabetes). In 2018, 18.6% of U.S. adults with diabetes were treated with insulin alone, and an additional 15.1% were treated with insulin and noninsulin glucose-lowering medications (7). The average list price of insulin in the United States rose by 15–17% each year between 2012 and 2016 (8). The greatest increase in insulin-related costs stems from greater use, and higher per-unit costs, of analog insulins (2). New insulin products such as ultra-long-acting or ultra-rapid-acting insulins offer important clinical and safety advantages to certain patients; however, these formulations are among the most expensive to obtain. Between the …

Pregestational diabetes is a condition in which a woman with diabetes (most commonly type 1 or type 2 diabetes) before the onset of pregnancy becomes pregnant and therefore vulnerable to increased risk for maternal and fetal adverse outcomes. Pregestational diabetes has been observed in 1–2% of all pregnancies, but rates are rising (1). Approximately one in nine women (14.9 million) have diabetes, and 35% of people with newly diagnosed diabetes are women of reproductive age (2). This means diabetes is increasingly affecting women of childbearing age. Furthermore, nearly one in five adolescents aged 12–18 years and one in four young adults aged 19–34 years are living with prediabetes, which has the potential to cross the threshold into diabetes (3). The increasing prevalence of diabetes among women of reproductive age is largely driven by an increase in type 2 diabetes, which in turn is driven by unhealthy nutrition, obesity, and increasingly sedentary lifestyles (4,5). Pregestational type 2 diabetes disproportionately affects women of ethnic minorities and disadvantaged socioeconomic status. For example, Pacific Islanders, Asian Indians, and Native Americans are more commonly affected by type 2 diabetes (6). In the United States, rates of pregestational diabetes have doubled since 1996, with ∼24% of women having preexisting type 1 diabetes and 76% having preexisting type 2 diabetes (7). The greatest increase is among Hispanic women. Moreover, women with pregestational type 2 diabetes are typically older (≥30 years of age) and more likely to be African American, Hispanic, or Asian (7). Thus, management of pregestational diabetes is not only a racial-ethnic equity issue, but is also important from a clinical impact standpoint. An estimated $327 million in direct medical costs and $90 billion in lost productivity could be saved by implementing comprehensive preconception care for all women diagnosed with diabetes (8). …

The proportion of patients with type 2 diabetes achieving recommended treatment goals remains suboptimal despite advances in diabetes care (1). Only 30% of patients with type 2 diabetes who use basal insulin achieve an A1C

Human regular U-500 insulin (U-500), a fivefold concentrated form of U-100 regular human insulin, was introduced to address the insulin needs of patients with severe insulin resistance (1). Severe insulin resistance has historically been characterized by patients with total daily insulin dose (TDD) requirements exceeding 200 units/day (1). With the increasing prevalence of diabetes and obesity in the United States, severe insulin resistance has become more common, increasing the need for U-500. The safe and effective use of U-500 requires careful monitoring to optimize glycemic control while minimizing the risk of hypoglycemia. The elevated risk of medication errors associated with U-500 therapy and a lack of clear guidelines for its use may have been responsible for its underutilization by both patients and health care providers (HCPs). In a survey administered to internal medicine physicians and ward nurses evaluating the inpatient use of U-500, 47% of respondents said they were “very uncomfortable” with the use of U-500 (2). A 2013 article published by the Institute for Safe Medication Practices (ISMP) reported on an increasing number of medication error reports and complaints from HCPs related to the use of U-500 (3). To address these medication errors, innovations (i.e., a dedicated U-500 syringe and a U-500 pen delivery device) have been developed to help solve dosing confusion issues and potentially enhance HCP and patient comfort with U-500 therapy. Here, we review the available evidence for U-500 and the innovations for its delivery. When considering the use of U-500, patients and HCPs must be aware of the unique pharmacokinetic/pharmacodynamic (PK/PD) profile that distinguishes it from both basal insulins and prandial insulins. Unlike other insulins, U-500 covers both the basal and prandial insulin needs of patients. This unique PK/PD profile allows for its use as monotherapy, and patients can inject smaller volumes with fewer injections …

The hemoglobin A1c (A1C) test is increasingly used as a diagnostic and screening test for type 2 diabetes. With an estimated 8.8% of adults globally having diabetes, effective screening, diagnosis, and monitoring is of major global importance (1). The biomarker of A1C refers to glycated hemoglobin A molecules and has gained prominence in the diagnosis of type 2 diabetes because it offers certain advantages over plasma glucose testing regimens (2). It is well established that some of the hundreds of hemoglobin (Hb) variants, including the clinically relevant HbS, HbE, HbC, and HbD (3,4), may interfere with the validity of A1C results. Thus, testing strategies and tools employing A1C should ideally identify variants when they are present. Incidental findings of Hb variants present several ethical challenges for laboratories, health care providers, patients, and their families. These challenges have, to date, received little attention. This article reviews some of the advantages of detecting sickle cell trait, identified by the routine A1C test, but also several related ethical dilemmas. We explore issues such as whether informed consent is necessary, how the results should be communicated, how patients may be affected by knowing their carrier status, the timing of communications, complications caused by partial results, and the circumstance of being a “healthy carrier” while potentially experiencing symptoms. A multidisciplinary team and a patient diagnosed as a sickle cell carrier through the A1C test worked together to explore these ethical challenges to produce this article. We hope it will instigate discussion around the issues presented and ultimately lead to the development of appropriate international guidelines. Sickle Hb (HbS) is one of the most common Hb variants. Worldwide, an estimated 300 million people have sickle cell trait (SCT) and ∼4.4 million people have sickle cell disease (SCD), the overall name for a group …

More than 29 million Americans have diabetes. The Centers for Disease Control and Prevention predict that the prevalence of diabetes will increase from 9% to >30% in the next 35 years (1). More than 21 million medical office visits for diabetes are scheduled each year (2). A total of one in five dollars spent on health care in the United States (and one in three dollars spent through Medicare) are spent on people with diabetes (3). With this in mind, proper and accurate coding for diabetes is a necessity. The International Classification of Diseases, 10th Revision—Clinical Modification (ICD-10) is designed to accurately classify and categorize all illnesses and diseases seen in the U.S. health care setting. (4) The coding system was updated in October 2015 to its 10th revision because it was thought that the 9th revision (ICD-9) no longer accommodated all of the new codes submitted to the system, and the ICD-9 codes were not descriptive enough to accurately reflect the state of patients’ diseases. For example, the ICD-9 system had 13,000 three- to five-digit codes. This system was not able to take in new codes and did not include a way to designate laterality. The ICD-10 system has 68,000 codes that are three to seven digits each and has the capacity to expand. In general, ICD-10 codes can be up to seven characters long and are designed as follows: XXX.XXX.X (category.anatomic site/severity.extension). The first set of digits before the first decimal point describes the general disease or category. The next three digits after the first decimal point describe the etiology, anatomical site, severity, or clinical detail. Finally, some conditions will have a second decimal point, followed by a final digit that may define an initial or subsequent encounter, the laterality of a condition, or the number of weeks’ …

The chronic consequences of hyperglycemia in diabetes are well documented. There is evidence that aggressive glycemic control is beneficial in certain populations. Therapy optimization occurs when ineffective medications are adjusted or new medications are added to achieve target glucose levels with minimal adverse events, specifically, hypoglycemia. Therapy selection and glycemic goals vary depending on diabetes type, duration, and comorbidities. Insulin is paramount in reaching A1C goals for many patients with type 2 diabetes. Relying on sliding-scale insulin, a method in which the patient reactively takes a predetermined number of units of bolus insulin per blood glucose level in response to hyperglycemic self-monitored blood glucose readings, as an effective means of controlling blood glucose is not supported by evidence-based medicine. Often, basal insulin alone is not sufficient because of declining β-cell function. Establishing a basal-bolus insulin regimen can achieve glycemic control even with daily fluctuations in carbohydrate intake. There are numerous anecdotal methods for initiating such therapy, but no consensus has developed. Health care providers must review recent literature on methods of optimizing bolus insulin to assist their patients in reaching glycemic targets and reducing the risk of hypoglycemia. Five simple steps to optimize bolus insulin therapy, as discussed below and summarized in Table 1, may provide people with diabetes and their health care teams with a guide for success. View this table: TABLE 1. Five Steps of Bolus Insulin Optimization In the landmark U.K. Prospective Diabetes Study (UKPDS), people with newly diagnosed type 2 diabetes in the intensive therapy arm were treated with sulfonylurea, metformin, or insulin and attained an A1C of 7% compared to 7.9% with standard therapy. Obtaining a lower A1C reduced microvascular complications by 25% over a median period of 11 years (1). Additionally, a long-term cohort follow-up demonstrated reduced cardiovascular events in the intensive therapy group (2). Results from …

The transition from urinary glucose measurement to more sophisticated self-monitoring of blood glucose (SMBG) systems in the 1970s and 1980s dramatically changed the approach to and understanding of diabetes management (1). Innovations in the design and technology of portable blood glucose meters have become integral to the success of intensive treatment of both type 1 and type 2 diabetes, and the outcome of this treatment has led to a tremendous decrease in the development of long-term micro- and macrovascular complications (2–4). However, intensive insulin therapy has its limitations, including increased frequency of hypoglycemia and the need for frequent SMBG testing. In the past decade, continuous glucose monitoring (CGM) technology has evolved into a novel tool to support diabetes management. Unlike conventional glucose meters, which provide a snapshot of the blood glucose value at the time of testing, CGM provides semi-continuous information about glucose levels. It does this indirectly, by extrapolating blood glucose levels from interstitial fluid glucose via an algorithm. Importantly, CGM allows users to make decisions regarding their day-to-day diabetes management using real-time glucose trends. Along with this information, CGM systems provide customizable hypo- and hyperglycemia alarms and display trends of the rate of change of glucose levels. Most recently, CGM systems have been integrated with insulin pumps and are being used in artificial pancreas clinical trials. In this article, we discuss the clinical benefits of CGM; its challenges, including accuracy and user experience; and its present and future role in the management of diabetes. Numerous studies have explored whether sustained use of CGM offers clinical benefits in individuals with diabetes. Randomized, multicenter clinical trials have shown improved glycemic control in adults with type 1 diabetes using CGM compared to those using SMBG and a reduction in the time spent in hypoglycemia with concomitant improvement in A1C …

Diabetes is a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood. This hyperglycemia results from either a deficiency of insulin secretion caused by pancreatic β-cell dysfunction or resistance to the action of insulin in liver and muscles, or both (1). Periodontal disease is one of the most common chronic inflammatory diseases and is characterized by gradual destruction of connective tissue surrounding the teeth, eventually leading to tooth loss. Periodontitis occurs primarily in adults, and its incidence increases with age (2). Type 2 diabetes and chronic periodontitis are both common in older age-groups. The relationship between both these diseases has been extensively studied. The prevalence of type 2 diabetes is increasing rapidly. According to World Health Organization estimates, the number of adults with diabetes worldwide will increase from 171 million in 2000 to 366 million by 2030 (3). India has been called “the diabetes capital of the world” because of its high diabetes rates; ∼41 million Indians have diabetes, accounting for one-fifth of all diabetes cases worldwide (4). The prevalence of periodontal disease in India is also alarming, with incidences of 296 million in 2000, 319 million in 2005, 341 million in 2010, and an estimated 363 million in 2015 (5). Both diabetes and periodontitis are more severe and progress more rapidly when these conditions occur simultaneously. Many studies have reported correlations between periodontal health and various diabetes-related factors such as A1C and duration of diabetes. In the U.S. Third National Health and Nutrition Examination Survey (2), adults with an A1C >9% had a significantly higher rate of severe periodontitis than those without diabetes. Periodontitis is considered a “sixth complication of diabetes” (6). A study by Williams and Mahan (7) involving 2,273 people with diabetes found a 60% prevalence of periodontal …

Much evidence supports the health benefits of consuming a plant-based diet and increasing the intake of legumes. A high intake of fruits, vegetables, whole grains, legumes (beans), nuts, and seeds is linked to significantly lower risks of heart disease, high blood pressure, stroke, and type 2 diabetes (1,2). The American Diabetes Association’s nutrition therapy recommendations for the management of adults with type 2 diabetes note that many eating patterns are acceptable for people with diabetes. Several diets, including the DASH (Dietary Approach to Stop Hypertension) and Mediterranean-style plans, although not strictly vegetarian, still promote increased intake of plant-based foods such as legumes and their associated health benefits (3). Although research supports the benefits of legume consumption, only ∼8% of U.S. adults report eating legumes on any given day (4). The purpose of this article is to highlight the research demonstrating the benefits of increasing legumes in the diet and to offer practical suggestions to aid health care providers in increasing their own legume intake and more confidently discussing such a goal with their patients. Unlike with some other chronic conditions, individuals who have type 2 diabetes are responsible for providing up to 95% of their own care (5). One of the most challenging aspects of type 2 diabetes care is helping patients adopt healthier behaviors. When nutrition therapy is provided by a qualified professional, people can learn how to make better food choices to help improve their glycemic control, blood pressure, cholesterol, and BMI (6). In fact, medical nutrition therapy (MNT), as provided by a registered dietitian, has been shown to improve glycemic control outcomes and reduce health care costs to Medicare (7). Recent literature demonstrates the benefit of augmenting this nutritional information with skills-based culinary education. Robust correlations exist between healthy food preparation skills and improved …

According to the most recent data from the Centers for Disease Control and Prevention, 25.8 million people in the United States (8.3% of the population) have diabetes (1). Type 2 diabetes accounts for 90–95% of diabetes diagnoses, and >85% of people with type 2 diabetes are overweight or obese (1). Increased BMI, which is common in the type 2 diabetes population, has a well-established association with symptoms of gastroesophageal reflux disease (GERD) (2,3). Central adiposity is an important risk factor in the development of reflux and, subsequently, erosive esophagitis, Barrett’s esophagus, esophageal adenocarcinoma, and gastric cardia adenocarcinoma (2,3). Increased BMI is not the only risk factor for the development of GERD, particularly among people with diabetes. Among those with type 2 diabetes, peripheral neuropathy is an independent risk factor for erosive esophagitis (4). In this population, there is a greater incidence of erosive esophagitis among individuals with neuropathy than among those without neuropathy, although those with and without neuropathy experience similar GERD symptoms (4). Approximately 60–70% of people with diabetes have mild to severe forms of nervous system damage, which may partly explain why low-grade esophageal dysplasia is twice as likely in individuals with than in those without diabetes (1,5). Additionally, both asymptomatic and symptomatic reflux is more prevalent in individuals with diabetes than in those without diabetes (6,7). Likewise, type 2 diabetes has been demonstrated to be a risk factor for symptomatic GERD (8). Among individuals with diabetes, 40.7% experience symptomatic GERD, and 70% of those use oral antidiabetic medications. Thus, it is likely that millions of individuals are managing blood glucose and GERD concomitantly with oral medications (1,7) Therefore, it is important to assess the drug interactions and clinical sequelae that may occur with this particular …

Diabetes is the most common endocrine disorder, affecting 8.3% of the population (1). Skin disorders will be present in 79.2% of people with diabetes (2). A study of 750 patients with diabetes found that the most common skin manifestations were cutaneous infections (47.5%), xerosis (26.4%), and inflammatory skin diseases (20.7%) (2). Individuals with type 2 diabetes are more likely than those with type 1 diabetes to develop cutaneous manifestations. Cutaneous disease can appear as the first sign of diabetes or may develop at any time in the course of the disease. This review provides a brief overview of skin conditions that primary care providers (PCPs) may encounter when treating patients with diabetes. ### Acanthosis Nigricans Acanthosis nigricans (AN) is likely the most readily recognized skin manifestation of diabetes (3). It is present in up to 74% of obese adult patients and can be predictive of the existence of hyperinsulinemia (4). The presence of AN is a prognostic indicator for developing type 2 diabetes. There is also a possible genetic predisposition or increased sensitivity of the skin to hyperinsulinemia in different ethnic groups. At the same obesity rates, prevalence of AN is lowest in whites (0.5%), higher in Hispanics (5%), and even higher in African Americans (13%) (5). AN is a hyperpigmented velvety thickening of skin folds, presenting predominantly in the neck, axilla, and groin areas (Fig. 1). Possible additional presentations could include skin tags and hyperkeratosis. Heredity, obesity, endocrine disorders, certain drugs, and malignancy are associated with AN. Benign AN type 2 is related to type 2 diabetes, and pseudo-AN type 3 is associated with the metabolic syndrome. Type 2 diabetes–related AN has an insidious onset and initially presents as hyperpigmentation. Both underlying conditions present with insulin resistance (3). Children aged 8–14 years who had AN were found to have insulin resistance, …

Optimal diabetes management requires patient engagement in a variety of self-care activities, including adherence to medication regimens, adjustment to lifestyle modifications, and monitoring of blood glucose levels. Perhaps one of the most challenging self-care issues facing patients living with diabetes is that of medication adherence. Patients take their medication as prescribed only 50% of the time (1) and are reluctant to share the details of their less-than-optimal medication-taking behavior with their health care providers (HCPs) (2). In 2003, the World Health Organization stated that increasing medication adherence might have a far greater impact on the health of the population than any improvement in specific medical treatments (3). During the past 14 years, a better understanding of the barriers related to nonadherence has become more apparent. The following barriers have been consistently implicated in medication nonadherence for patients with diabetes: patients’ emotions, patients’ intention to not take medications, emotional distance from HCPs (e.g., because of HCPs’ poor understanding of the situation), social and cultural beliefs about health and antidiabetes medications, low health literacy, insufficient information about ancillary resources, medication complexity and lack of support or powerlessness to handle medication complexity, and poverty (4). Researchers have also documented the consequences of nonadherence, which include increased morbidity, mortality, and health care costs (5). Although the body of knowledge informing the issues of medication nonadherence has grown, the practical problem of medication adherence is one that patients and providers continue to struggle with on a daily basis. The National Diabetes Education Program developed a web resource titled “Promoting Medication Adherence in Diabetes,” available at www.niddk.nih.gov, to give HCPs evidence and tools to help them promote optimal medication-taking behavior among patients. To help busy HCPs, we have distilled the current knowledge base related to medication nonadherence in patients with diabetes into this practical …

P rimary care, according to the American Association of Family Physicians, is “care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.”1 Primary care forms the backbone of our health care system, providing the first line of contact for innumerable patients who may be referred to specialists based on specific clinical needs. In the United States, there is a shortage and maldistribution of primary care providers,2 and the increasing number of urgent care clinics that are frequently staffed with mid-level providers adds further testimony to the growing problem of disparities in health care.2,3 It is believed that in the United States, the impact of this shortage will be felt much more in the coming years because of the rising proportion of elderly people, who present with chronic medical illnesses.4 One suggestion to alleviate the primary care shortage is to effectively utilize the available paramedical workforce that includes nurses and other ancillary personnel as points of entry to primary care.5 Among them, dentists, as de facto oral physicians who already play a pivotal role in monitoring medical conditions such as hypertension during patient visits, can be a valuable medical resource.6 Many elderly patients see their dentists more routinely than their medical health care providers (HCPs).7 If dentists or their staffs are adequately trained to identify, monitor, and refer common chronic medical ailments, they can be a good first line of contact in the existing health care system.8 It is equally important that HCPs have the knowledge and training to diagnose common dental conditions. Because of the intricate relationship between …

In providing the best care for patients, health care providers (HCPs) rely on clinical experience and judgment, published literature, and evidence-based clinical guidelines to direct decisions and serve as benchmarks for achieving optimal patient outcomes. Several published guidelines are available to support HCPs in caring for patients with type 2 diabetes. These include recommendations from the American Diabetes Association (ADA),1 the World Health Organization (WHO),2 the American Association of Clinical Endocrinologists (AACE),3 the Indian Health Service (IHS),4 and the Center for Medicaid and Medicare Services (CMS).5 These guidelines are kept current through periodic review of available literature and research to ensure that they are up to date and based on the latest available evidence. Practicing clinicians and the various guideline development committees have diverse perspectives regarding how best to incorporate published research findings into clinical practice when managing patients with a disease as complex as type 2 diabetes. We conducted an evaluation to identify consistencies and discrepancies among the guidelines for nonpregnant adults with type 2 diabetes in the areas of screening, diagnosis, management, and prevention. The ADA, WHO, and IHS guidelines recommend that adults be evaluated for type 2 diabetes if they are overweight (BMI ≥ 25 kg/m2) and have one or more of the following risk factors: first-degree relative with diabetes, women who delivered a baby weighing > 9 lb, diagnosis of hypertension > 140/90 mmHg, diagnosis of polycystic ovarian syndrome, history of gestational diabetes mellitus (GDM), or acanthosis nigricans (Table 1).1,2,4 However, several minor differences do exist among the guidelines. The ADA1 recommends that adults with prediabetes be screened annually and that adults who are ≥ 45 years of age without preexisting conditions be screened every 3 years. The WHO2 recommends that adults …

Gestational diabetes mellitus (GDM) is increasingly acknowledged as a public health problem in developing countries, resulting in both immediate and long-term health effects for mothers and their newborns (1,2). Maternal and fetal complications of GDM range from adaptation problems of the newborn (e.g., asphyxia, respiratory distress, and hypoglycemia) to major obstetric complications such as shoulder dystocia, prolonged or obstructed labor, preeclampsia, or postpartum hemorrhage (2,3). In low-resource settings, where shortages of health care providers as well as lack of skills to manage such complications prevail (4), untreated GDM and its associated conditions can endanger the life of mothers and their newborns. Screening and management of GDM often is not part of routine care in the majority of low-resource settings. Because of this, data on the prevalence of GDM and the incidence of related obstetric and newborn complications are scarce. Most of the research on GDM to date has been conducted in high-income countries where GDM screening is already an established part of antenatal care, and specific procedures are clearly defined in national guidelines. Such guidelines are often absent in low-resource settings where, until now, GDM has played a minor role in the shadow of more obvious determinants of maternal and perinatal morbidity and mortality. Where guidelines are available, they often are not standardized. In various GDM projects in low-resource settings, different guidelines have been used for screening and subsequently had to be adapted to fit into the local context (5). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome study (6), the World Health Organization (WHO) modified previously recommended criteria for the diagnosis of GDM (7) to serve as a basis for universal guidelines. This review will assess which criteria are applied by countries with routine screening for GDM in place and how congruent …