Guidelines

In October 2008, the IDF Task Force on Clinical Guidelines, in conjunction with the Self-Monitoring of Blood Glucose nternational Working Group, convened a workshop in Amsterdam to address the use of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes who are not treated with insulin. The recently published guidelines on the use of SMBG in people with type 2 diabetes were developed based on the findings of that workshop. A summary of the findings and recommendations is provided in this article.

Recently, two clinical trials addressed the role of tight blood glucose control on cardiovascular risk in people with type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the Action in Diabetes and Vascular Disease (ADVANCE) trial. The ACCORD study included 10,251 people with type 2 diabetes and was designed to determine whether intensive blood glucose control (HbA1c below 6%) as compared to a conventional approach (HbA1c between 7% and 7.9%) would result in favourable cardiovascular outcomes in people with type 2 diabetes at high vascular risk.

Haemoglobin A1c (HbA1c) is widely used to determine levels of long-term blood glucose, judge the adequacy of diabetes management, and adjust therapies. HbA1c results are expressed as the percentage of haemoglobin that is exposed to glucose (glycated). People’s day-to-day diabetes management is guided by self-monitoring of  capillary glucose concentrations, which are measured  in mmol/l or mg/dl.

Since the late 1970s, HbA1c test results have been used to guide diabetes care. The International A1c-AG Study, under way in 10 centres in North America, Europe, and Africa, aims to explore the relationship between HbA1c and average blood glucose. Martin Silink and Jean-Claude Mbanya, who represent IDF on a consensus committee working towards the standardization of the HbA1c assay, report on developments in the measurement and reporting of long- term average blood glucose levels.

The importance of identifying children who are at risk of developing the metabolic syndrome cannot be underestimated. The syndrome is a cluster of risk factors

Diabetes is a leading cause of death in most developed countries, and has become a serious epidemic in many developing and newly industrialized nations. Currently, an estimated 246 million people worldwide have diabetes. Poorly controlled diabetes is associated with disabling and potentially life-threatening complications such as eye disease, kidney disease, nerve damage and cardiovascular disease. Until recently, lowering fasting and pre-meal glucose levels was a key focus of diabetes management.

It is often stated that dietary management is a cornerstone of diabetes care. More recently, physical activity has also been recognized as a useful fundamental intervention. When it is realized that both of these can affect a variety of the problems that bedevil people with diabetes – including excess body weight, high blood glucose levels, high blood fat levels, and high blood pressure – it is not difficult to see why these issues might be regarded as fundamental.

People with diabetes deliver most of their own care. This reflects the observation that diabetes and its associated features touch on most aspects of daily living, and aspects as fundamental as eating and physical activity. To deliver such care requires knowledge, but even with knowledge it may not be easy to adjust to optimal self-care. This makes patient education a complex therapeutic issue.

Diabetes care is inherently complex – hence the need for 19 chapters of evidence review and recommendations in the Global Guideline. Pulling all the recommendations together to ensure the implementation of effective delivery of care therefore needs some organization of its own, as is discussed in this article. A special situation is that of people with diabetes in hospital, who are often subject to disruption of lifestyle due to illness, procedures, or surgery, with knock-on effects on their diabetes management.