EAL

Recommendations Summary

PDM: Screen for Type 2 Diabetes Risk 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

Recommendation(s)
PDM: Screen for Type 2 Diabetes Risk

The registered dietitian nutritionist (RDN) should ensure that all individuals are screened for risk of type 2 diabetes, using a recognized screening tool (such as the American Diabetes Association Type 2 Diabetes Risk Test, http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/). The prevalence and socioeconomic burden of type 2 diabetes and associated co-morbidities are rising worldwide, and individuals who are at high risk for type 2 diabetes should be prioritized for intensive intervention to delay the onset of disease.

Rating: Consensus
Imperative

PDM: Determine Appropriate Action Based on Screening

The registered dietitian nutritionist (RDN) should collaborate with other healthcare providers to determine the appropriate actions to be taken, based on the results of the screening:
- Re-screening three years later if tests are normal
- General advice about risk factors and development of diabetes
- Referral to healthcare provider for laboratory work and other medical tests
- Referral for weight reduction, including medical nutrition therapy (MNT) for Adult Weight Management
- Referral for type 2 diabetes prevention program, including MNT for Prevention of Type 2 Diabetes in high-risk groups
- Referral for diabetes therapy, including MNT for Diabetes.
The prevalence and socioeconomic burden of type 2 diabetes and associated co-morbidities are rising worldwide, and individuals who are at high risk for type 2 diabetes should be prioritized for intensive intervention to delay the onset of disease.

Rating: Consensus
Imperative
- Risks/Harms of Implementing This Recommendation
  Potential for negative psychological effect from screening for diabetes risk (for example, emotional distress and denial).
- Conditions of Application
  - One barrier may be limited time and resources available for screening and implementing appropriate action, in the large and growing population of high-risk individuals
  - For evidence-based practice guidelines on MNT, please refer to the following projects:
    
    Adult Weight Management Evidence-Based Nutrition Practice Guideline: http://andevidencelibrary.com/topic.cfm?cat=2798
    
    Diabetes Evidence-Based Nutrition Practice Guideline: http://andevidencelibrary.com/topic.cfm?cat=3251.
- Potential Costs Associated with Application
  - Implementing the screening program
  - Screening will identify more individuals that need medical nutrition therapy (MNT)
  - The cost of appropriate actions, including MNT and ongoing support.
- Recommendation Narrative
  From Prevention/Delay of Type 2 Diabetes Recommendations from the American Diabetes Association Standards of Medical Care, 2014
  - Testing to detect type 2 diabetes and prediabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI more than 25kg/m²) and who have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45 years. (B)
  - If tests are normal, repeat testing at least at three-year intervals is reasonable (E)
  - To test for diabetes or prediabetes, the A1C, FPG, or two-hour 75g OGTT are appropriate (B)
  - In those identified with prediabetes, identify and, if appropriate, treat other CVD risk factors. (B)
  From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010
  - A community-based strategy should consist of using a screening test as a first step in order to estimate the risk for current diabetes or prediabetes and the risk for future diabetes. It is recommended the use of opportunistic screening by healthcare personnel, including those working in general practice, nurses and pharmacists. If after this first step a person is considered to be at increased risk for diabetes, they will proceed to PG measurements (either fasting or preferably using an OGTT) in order to determine more precisely their glycemic status (Grade A).
  - In routine clinical practice, a screening strategy should be targeted to patients with at least one obvious risk factor for diabetes. It may consist of PG measurement at fasting or even better of OGTT due to its higher sensitivity. One alternative may be a stepped approach including an initial screening questionnaire (score of risk for diabetes) in the process. As examples, due to the very high number of obese subjects, OGTT is best reserved for those with higher scores, whereas the very prevalence of diabetes or prediabetes in CVD patients suggests that performing OGTT regularly in these patients is the best strategy (Grade B).
  - Performance of diabetes risk scores must be assessed in the target population where they will be ultimately applied (Grade B)
  - After scoring for diabetes risk, it is mandatory to inform participants about their risk and to take time to deliver explanations, in particular to lower-educated individuals. This needs to be done appropriately in order to raise the awareness and understanding of T2DM and its risk factors, while avoiding or minimizing negative effects, such as emotional distress and denial (Grade A).
  - As OGTT has a higher sensitivity than FPG for detecting diabetes and is the only test to detect IGT, a definite categorization of glycemic state needs an OGTT (Grade A).
- Recommendation Strength Rationale
  From Prevention/Delay of Type 2 Diabetes Recommendations from the American Diabetes Association Standards of Medical Care, 2014
  - The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
  - Evidence in support of the recommendation was grades B and E.
  From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010
  - The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
  - Evidence in support of the recommendation was grades A and B.
- Minority Opinions
  Consensus reached.

Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
- References
- References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
  American Diabetes Association. Standards of medical care in diabetes: 2014. Diabetes Care. 2014; 37 Suppl 1: S14-S80.
  
  Lindström J, Neumann A, Sheppard KE, Gilis-Januszewska A, Greaves CJ, Handke U, Pajunen P, Puhl S, Pölönen A, Rissanen A, Roden M, Stemper T, Telle-Hjellset V, Tuomilehto J, Velickiene D, Schwarz PE, Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen M, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. Take action to prevent diabetes: The IMAGE toolkit for the prevention of type 2 diabetes in Europe. Horm Metab Res. 2010 Apr; 42 Suppl 1: S37-S55.
  
  Pajunen P, Landgraf R, Muylle F, Neumann A, Lindström J, Schwarz PE, Peltonen M, Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen M, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. Quality indicators for the prevention of type 2 diabetes in Europe: IMAGE. Horm Metab Res. 2010 Apr; 42 Suppl 1: S56-S63.
  
  Paulweber B, Valensi P, Lindström J, Lalic NM, Greaves CJ, McKee M, Kissimova-Skarbek K, Liatis S, Cosson E, Szendroedi J, Sheppard KE, Charlesworth K, Felton AM, Hall M, Rissannen A, Tuomilehto J, Schwarz PE, Roden M, for the Writing Group: Paulweber M, Stadlmayr A, Kedenko L, Katsilambros N, Makrilakis K, Kamenov Z, Evans P, Gilis-Januszewska A, Lalic K, Jotic A, Djordevic P, Dimitrijevic-Sreckovic V, Hühmer U, Kulzer B, Puhl S, Lee-Barkey YH, AlKerwi A, Abraham C, Hardeman W, on behalf of the IMAGE Study Group: Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen B, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. A European evidence-based guideline for the prevention of type 2 diabetes. Horm Metab Res. 2010 Apr; 42 Suppl 1: S3-S36.