(Andes et al., 2020). While prediabetes is not a separate disease state, it is a risk factor for the progression to diabetes. Prediabetes also poses several cardiovascular risks, and patients with elevated plasma glucose and/or HbA1C should be screened for other car- diovascular complications.
Self-Assessment Quiz Question #2 Billy undergoes testing for prediabetes and diabetes. Which of the following findings meets American Diabetes Association criteria for diabetes diagnosis? Note that Billy’s last meal was 6 hours prior to testing.
a. Plasma glucose of 126 mg/dL. b. Plasma glucose of 180 mg/dL.
c. Hemoglobin A1C of 6%. d. Hemoglobin A1C of 8%. COMPLICATIONS AND RELATED CONDITIONS
Chronic complications of T2DM are tied directly to the degree and duration of sustained hyperglycemia (ADA et al., 2022a). Comor- bidities, including hyperlipidemia and hypertension, may already be present at diagnosis and should be detected and treated as early as possible (ADA et al., 2022g). Polycystic ovary syndrome (PCOS), a complex endocrine disorder that causes menstrual ir- regularities, is bidirectionally associated with T2DM (Cioana et al., 2022). Insulin resistance contributes to the pathogenesis of PCOS, and PCOS contributes to decreased insulin sensitivity. The syndrome is also associated with many cardiometabolic diseases and mental health disorders. A recent systematic review and me- ta-analysis estimates that up to one in five girls with T2DM are diagnosed with PCOS (Cioana et al., 2022). Although diagnostic criteria varied among the included studies, this high percentage highlights the importance of assessment for PCOS in the T2DM population. Microvascular and macrovascular complications, along with dia- betes-associated conditions, should be actively screened for and treated, as appropriate (ADA et al., 2022g). Table 1 summarizes recommendations regarding onset of screening and follow-up frequency. Specific treatment of these conditions, if detected, is beyond the scope of this course. Generally, glycemic control and lifestyle modifications can serve as prevention and therapy for a majority of the listed conditions. Although preventing complications is centered on glycemic con- trol and lifestyle modifications, additional interventions can im - prove patient health and quality of life (ADA et al., 2022c). As an example, oral contraceptive pills may be utilized in the treatment of PCOS and to prevent unplanned pregnancies in adolescent girls. Beginning at the onset of puberty, females should be coun- seled about the potential risks to a fetus exposed to poor meta- bolic control. In those who are or who plan to become sexually active, effective contraceptive methods should be discussed and provided (ADA et al., 2022g). Children with diabetes are at increased risk of infection due to alterations in the immune system (Calliari et al., 2020). Possible mechanisms include decreased T-cell response, reduced neutro- phil function, and microbiome alterations. The etiology of this dysfunction is attributed to prolonged periods of hyperglycemia in addition to factors associated with pathophysiology and treat- ment of the disease. In turn, active infection creates stress on the body, which results in hyperglycemia and insulin resistance. During periods of illness, blood glucose should be monitored more frequently, and patients should remain adequately hydrated to prevent escalation to DKA or HHS.
Table 1: Screening for Complications and Diabetes- Associated Conditions Condition Type of Screening Onset of Screening
Follow-Up, if Normal
Nephropathy Albu-
Upon diagnosis Annually
min-to-creati- nine ratio
Neuropathy Foot exam Upon diagnosis Annually Retinopathy Dilated fun- doscopy Soon after diag- nosis Annually Dyslipidemia Lipid profile Annually
After resolution of hyperglyce- mia
Hypertension Blood pres- sure monitor- ing
Upon diagnosis
Every office visit
Nonalcoholic fatty liver disease Obstructive sleep apnea Polycystic ovarian syn- drome
Liver en- zymes
Upon diagnosis Annually
Symptom screening Symptom screening
Upon diagnosis
Every office visit Every office visit
Upon diagnosis (female adoles- cents)
Note : Adapted from American Diabetes Association Professional Practice Committee, Draznin, B., Aroda, V. R., Bakris, G., Benson, G., Brown, F. M., Freeman, R., Green, J., Huang, E., Isaacs, D., Kahan, S., Leon, J., Lyons, S. K., Peters, A. L., Prahalad, P., Reusch, J., & Young- Hyman, D. (2022g). Children and adolescents: Standards of medical in diabetes, 2022. Diabetes Care, 45 (Suppl 1), S208-S231. https://doi. org/10.2337/dc22-S014 Common sites of infection include the respiratory tract, skin and soft tissue, the urinary tract, and surgical sites (Calliari et al., 2020). Candidiasis is also common, especially in the vulvovaginal area, as previously discussed. Hyperglycemia increases urinary excre- tion of glucose, which serves as a nutrient for Candida . Therefore, inadequate glycemic control increases the risk of Candida coloni- zation. Colonization increases with age, especially in the postpu- bertal period, and may result in clinical infection. In children, respiratory infections are the most common infectious process, and two of the main causes are Streptococcus pneumo- niae and influenza viruses. Although adequate glycemic control can help regulate the immune system and potentially prevent in- fections, immunizations are a key strategy in reducing morbidity and mortality in this population. The ADA (2022g) recommends all children with diabetes receive age-based standard immuniza- tions, including influenza and high-risk pneumococcal vaccines. All children are recommended to receive the pneumococcal con-
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