The primary therapeutic goal of obesity management is improvement in adiposity-related complications, not a preset decline in body weight. Lifestyle intervention is a vital component of all weight loss regimens; the choice of whether to implement lifestyle therapy alone or combine it with weight-loss medications or bariatric surgery will depend on the severity of each individual patient’s obesity and related complications.1
Obesity prevalence has risen steadily for several decades, and the disease, its complications, and comorbidities place a huge burden on patients and society. Obesity is estimated to add $3,559 annually (adjusted to 2012 dollars) to per-patient medical expenditures as compared to patients who do not have obesity; this includes $1,372 each year for inpatient services, $1,057 for outpatient services, and $1,130 for prescription drugs.
AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations
Type 1 diabetes (T1D) is a chronic autoimmune disorder that occurs in genetically susceptible individuals and that may be precipitated by environmental factors. In a susceptible individual, the immune system is triggered to develop an autoimmune response against altered pancreatic beta cell antigens, or molecules in beta cells that resemble a viral protein.
Epidemiologic data have demonstrated significant increases of various cancers in people with obesity and diabetes. Recently, concern has emerged that antihyperglycemic medications may also be associated with an increased prevalence of multiple cancers; however, available data are limited and conflicting.1,2
Screening for Prediabetes
AACE recommends that individuals who meet any of the clinical risk criteria noted below should be screened for prediabetes or type 2 diabetes (T2D) (1).
The primary goal of prediabetes management is to normalize glucose levels and prevent or delay progression to diabetes and associated microvascular complications.
Overall, type 1 diabetes (T1D) accounts for approximately 5% of diabetes and affects about 20 million individuals worldwide. Among those younger than 20 years of age, T1D accounts for the majority of T1D cases (1,2). The current U.S. prevalence estimate of 1-3 million T1D patients may triple by 2050 due to a rising incidence of T1D (3).
Patients with type 1 diabetes (T1D) require exogenous insulin for survival and should be identified as soon as possible to avoid high morbidity due to a delay in insulin treatment.
Diabetes affects 9.4% of the population of the United States, or approximately 30.3 million people. Of these, 7.2 million have not been diagnosed. Approximately 90% of all diabetes cases are type 2 diabetes.1
The risk factors for the development of both prediabetes and type 2 diabetes mellitus (T2DM) are as follows:1
There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes. AACE-defined glucose tolerance categories are listed in Table 1.1
Table 1. Glucose Testing and Interpretation1
The Comprehensive Care Plan
As may be expected with a chronic disease that primarily affects middle-aged and older individuals, type 2 diabetes is usually complicated by other medical conditions.
Epidemiologic studies show that glucose control in hospitals is woefully inadequate.
Approximately 30% of hospitalized patients have blood glucose values >180 mg/dL.
Hyperglycemia and insulin regulation play both a direct and indirect role in the cellular mechanisms underlying inflammation and oxidative stress.
Free fatty acids generated by hyperglycemia and insulin deficiency also result in endothelial dysfunction and the generation of reactive oxygen species.
Diabetes is an increasingly prevalent diagnosis among hospitalized patients.
Many patients have unrecognized diabetes.
Diabetes contributes to greater lengths of stay and increased costs among hospitalized patients.
Identifying and treating diabetes:
Hyperglycemia is common in critically ill patients, both with and without diabetes.
Hyperglycemia is a predictor of adverse outcomes, including mortality.
Hyperglycemia is associated with poor outcomes in noncritically ill patients.
Glycemic goals for noncritically ill patients
Premeal blood glucose: <140 mg/dL
Random blood glucose: <180 mg/dL
DKA and HHS are life-threatening emergencies.
Attention to precipitating cause
Fluid and electrolyte management
Prevention of metabolic complications during recovery
Hyperglycemia is associated with adverse clinical outcomes in the hospital setting, both in critically ill and noncritically ill patients.
Various patient- and provider-specific factors may increase the risk of inpatient hypoglycemia
Insulin is the most appropriate agent for the majority of hospitalized patients.
Insulin is a “high-alert medication.”
Nurses are essential—and central—to successful implementation of protocols, order sets, glucose monitoring, and educational programs to support improved glycemic control.
The last 18 hours in utero have a significant impact on the infant’s metabolic responses after birth, even if maternal glucose control is adequate over the duration of gestation.
The order sets provided here are only a few examples from institutions involved in the management of inpatient hyperglycemia; this is not an all-inclusive list. Posting of these protocols does not constitute endorsement of any specific protocol. We believe that each institution should consult with diabetes experts to select and implement insulin protocols.
Hyperglycemia in the hospital affects quality of care, patient safety, length of stay, and cost; hence, addressing hyperglycemia in hospitalized patients can unite professionals in a common quest.
Models for implementation of improved control of hyperglycemia include:
Glucometrics is a way to measure the success of inpatient glucose management. Getting timely and accurate metrics to frontline clinical teams, which can analyze the results and look for cause and effect, will transform performance improvement into optimal outcomes.
Upon admission (or as soon thereafter as possible), every patient’s need for diabetes education should be assessed.
During hospital stay, all patients with diabetes should receive necessary training in diabetes knowledge and self-care skills.
Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia).
The treatment goals for patients with type 1 diabetes (T1D) are the same as those for patients with type 2 diabetes (T2D), as outlined in Table 1 (1).
Table 1. Glucose goals for patients with diabetes (1).
Comprehensive care of patients with diabetes requires a team of healthcare professionals. Working with different healthcare providers allows the patient to learn in-depth information regarding their health and well-being. It also ensures that the patient’s needs are cared for and addressed.
Access practical tools that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of osteoporosis and other bone-related disorders.