This statement provides guidance for diabetes care in detention facilities. It focuses on areas where the processes for delivery of care to people with diabetes in detention facilities may differ from those in the community, and key points are made at the end of each section. Areas of emphasis, which inform multiple aspects discussed in this statement, include 1) timely identification or diagnosis of diabetes treatment needs and continuity of care (at reception/intake, during transfers, and upon discharge), 2) nutrition and physical activity, 3) timely access to diabetes management tools (insulin, blood glucose monitoring, tracking data, current diabetes management technologies, etc.), and 4) treatment of the whole person with diabetes (self-management education, mental health support, monitoring and addressing long-term complications, specialty care, etc.).

Background: In 1959, the Department of Transportation enacted safety regulations that included a blanket ban on insulin use by pilots. In 1996, in response to American Diabetes Association® (ADA) advocacy, the Federal Aviation Administration (FAA) began allowing insulin-treated (ITDM) pilots to fly privately. The success of this program led to approximately 500 pilots certified to fly privately with no adverse events related to diabetes. Nonetheless, the ban on insulin use remained intact for commercial pilots. Some ITDM pilots continued working but chose to avoid insulin and accept the resulting increased hyperglycemia and long term complications. Interventions: The ADA began a strategy of multi-disciplinary interventions to reverse the blanket ban, including engaging “grassroots” and “grasstops” advocates, litigation, and legislative efforts. In 2014, an expert ADA medical panel reviewed relevant National Transportation and Safety Board data and recommended criteria to identify pilots capable of avoiding hypo and hyperglycemia in flight. When the FAA remained reluctant to overturn its longstanding policy, ADA continued its advocacy to encourage the FAA to adopt its recommendations by providing legal and medical support to ITDM pilots engaged in litigation against the FAA. Increasingly accurate continuous glucose monitoring (CGM) technology contributed to the FAA’s decision to overturn the blanket ban. Indeed, the new protocol requires pilots to use a CGM. Results: In November 2019 the FAA published a new protocol for insulin-treated commercial pilots which eliminates the blanket ban. Conclusions: The ADA’s unique structure and position enabled it to take the lead in dramatically improving the lives of pilots with diabetes. This achievement follows the ADA’s accomplishments for commercial drivers with diabetes and demonstrates that the ADA’s interdisciplinary collaboration model is successful in overcoming barriers to employment for people with diabetes. Disclosure D. Lorber: None. S. Fech-Baughman: None.

In 2018 the Department of Transportation (DOT) published a new rule on the requirements for medical certification of commercial motor vehicle (CMV) drivers with insulin-treated diabetes mellitus. This rule eliminates significant obstacles for those drivers, thus potentially enabling thousands of drivers to pursue careers that had previously been unavailable to them. This poster reviews the process of CMV medical certification for drivers with insulin-treated diabetes and provides resources and guidance for the assessment process. The new rule requires an assessment by a treating clinician (defined as a healthcare professional who manages, and prescribes insulin for, treatment of the individual’s diabetes mellitus as authorized by the healthcare professional’s applicable state licensing authority). The components of this assessment include: • A minimum of 3 months of blood glucose self-monitoring records measured with a glucometer that stores all readings from which data can be downloaded. • Hypoglycemia history. • Hemoglobin A1C measurements. • Complications of diabetes. The treating clinician completes an assessment form to determine whether the driver meets the physical qualification standards of the Federal Motor Carrier Safety Administration (FMCSA) to operate a CMV. Additional assessment by the treating clinician may be required if the driver has recently experienced a motor vehicle accident or severe hypoglycemic episode. The treating clinician is required to attest the driver maintains a “stable insulin regimen” and “proper control of his/her diabetes mellitus.” The American Diabetes Association provides a useful online calculator to assess the risk of a diabetes related motor vehicle accident (professional.diabetes.org/RADD) Although the rule requires an opinion from a treating clinician, the final decision on medical certification for any individual CMV driver is made by a certified medical examiner listed on the National Registry of Certified Medical Examiners. Disclosure D. Lorber: None. K. Hathaway: None.

Background: The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study has enrolled a racially and ethnically diverse population with type 2 diabetes, performed extensive phenotyping, and randomly assigned the participants to one of four second-line diabetes medications. The continuous glucose monitoring (CGM) substudy has been added to determine whether there are racial/ethnic differences in the relationship between average glucose (AG) and hemoglobin A1c (HbA1c). CGM will also be used to compare time in target range, glucose variability, and the frequency and duration of hypoglycemia across study groups. Methods: The observational CGM substudy will enroll up to 1800 of the 5047 GRADE study participants from the four treatment groups, including as many as 450 participants from each of 4 racial/ethnic minority groups to be compared: Hispanic White, non-Hispanic White, non-Hispanic African American, and non-Hispanic Other. CGM will be performed for 2 weeks in proximity to a GRADE annual visit, during which an oral glucose tolerance test will be performed and HbA1c and glycated albumin measured. Indicators of interindividual variation in red blood cell turnover, based on specialized erythrocyte measurements, will also be measured to explore the potential causes of interindividual HbA1c variations. Conclusions: The GRADE CGM substudy will provide new insights into whether differences exist in the relationship between HbA1c and AG among different racial/ethnic groups and whether glycemic profiles differ among frequently used diabetes medications and their potential clinical implications. Understanding such differences is important for clinical care and adjustment of diabetes medications in patients of different races or ethnicities.

Background: The prevalence of diabetes in the United States commercial motor vehicle (CMV) driver population is more than twice that of other adults in the U.S. working population. This population is at high risk for type 2 diabetes and for requiring insulin. With the development of the federal highway system and the dramatic increase in interstate commercial driving, in 1970 the Department of Transportation (DOT) put in place safety regulations that included an absolute blanket ban on insulin use. The impact of these regulations for CMV drivers with diabetes was to eliminate an entire career path or choose to avoid insulin with the resulting increased hyperglycemia and long-term sequelae of uncontrolled diabetes. Interventions: In response to this blanket ban, the American Diabetes Association (ADA), including representation from its advocacy and scientific and medical arms began a strategy of multi-year, multi-disciplinary interventions to address and reverse the blanket ban. From “grassroots” to “grasstops” advocates, every level of the ADA lobbied for this important change. Two diabetes expert panels reviewed relevant data and provided recommendations to both Congress and the DOT. In 2010 ADA convened an expert panel to develop a position statement on Diabetes and Driving. It was necessary for ADA to overcome objections from both a DOT medical review board and other interested parties. The process was characterized by ever-changing obstacles requiring ADA to stay the course for over a decade. Results: In 2018 the DOT published a new rule on diabetes eliminating the ban against insulin use and simplifying the process of CMV licensure for thousands of insulin-treated drivers. Conclusions: The ADA’s unique structure and position enabled it to take the lead in dramatically improving the lives of CMV drivers with diabetes. This achievement provides a model for future interdisciplinary collaboration to overcome barriers to employment for people with diabetes. Disclosure D. Lorber: None. K. Hathaway: None.

The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease.This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years.A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p < 0.001). Among patients with low SYNTAX scores (≤22), major cardiovascular events did not differ significantly between revascularization and medical therapy, either in the CABG stratum (26.1% vs. 29.9%, p = 0.41) or in the PCI stratum (17.8% vs. 19.2%, p = 0.84). Among patients with mid/high SYNTAX scores, however, major cardiovascular events were lower after revascularization than with medical therapy in the CABG stratum (15.3% vs. 30.3%, p = 0.02), but not in the PCI stratum (35.6% vs. 26.5%, p = 0.12).Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305).

The objective of this study was to assess the effect of sitagliptin on insulin dose in patients with inadequately controlled type 2 diabetes who titrate basal insulin to a target fasting glucose level after initiating sitagliptin.

OBJECTIVE To compare the efficacy and safety of Technosphere insulin (TI) and insulin aspart in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS This open-label noninferiority trial compared the change in HbA1c from baseline to week 24 of prandial TI (n = 174) with that of subcutaneous aspart (n = 171), both with basal insulin, in patients with type 1 diabetes and HbA1c 7.5–10.0% (56.8–86.0 mmol/mol). RESULTS Mean change in HbA1c in TI patients (–0.21% [–2.3 mmol/mol]) from baseline (7.94% [63.3 mmol/mol]) was noninferior to that in aspart patients (–0.40% [–4.4 mmol/mol]) from baseline (7.92% [63.1 mmol/mol]). The between-group difference was 0.19% (2.1 mmol/mol) (95% CI 0.02–0.36), satisfying the noninferiority margin of 0.4%. However, more aspart patients achieved HbA1c <7.0% (53.0 mmol/mol) (30.7% vs. 18.3%). TI patients had a small weight loss (–0.4 kg) compared with a gain (+0.9 kg) for aspart patients (P = 0.0102). TI patients had a lower hypoglycemia event rate than aspart patients (9.8 vs. 14.0 events/patient-month, P < 0.0001). Cough (generally mild) was the most frequent adverse event (31.6% with TI, 2.3% with aspart), leading to discontinuation in 5.7% of patients. Treatment group difference for mean change from baseline in forced expiratory volume in 1 s was small (40 mL) and disappeared upon TI discontinuation. CONCLUSIONS In patients with type 1 diabetes receiving basal insulin, HbA1c reduction with TI was noninferior to that of aspart, with less hypoglycemia and less weight gain but increased incidence of cough.

Type 2 diabetes mellitus (T2DM) is commonly accompanied by other cardiovascular disease (CVD) risk factors, such as hypertension, obesity, and dyslipidemia. Furthermore, CVD is the most common cause of death in people with T2DM. It is therefore of critical importance to minimize the risk of macrovascular complications by carefully managing modifiable CVD risk factors in patients with T2DM. Therapeutic strategies should include lifestyle and pharmacological interventions targeting hyperglycemia, hypertension, dyslipidemia, obesity, cigarette smoking, physical inactivity, and prothrombotic factors. This article discusses the impact of modifying these CVD risk factors in the context of T2DM; the clinical evidence is summarized, and current guidelines are also discussed. The cardiovascular benefits of smoking cessation, increasing physical activity, and reducing low-density lipoprotein cholesterol and blood pressure are well established. For aspirin therapy, any cardiovascular benefits must be balanced against the associated bleeding risk, with current evidence supporting this strategy only in certain patients who are at increased CVD risk. Although overweight, obesity, and hyperglycemia are clearly associated with increased cardiovascular risk, the effect of their modification on this risk is less well defined by available clinical trial evidence. However, for glucose-lowering drugs, further evidence is expected from several ongoing cardiovascular outcome trials. Taken together, the evidence highlights the value of early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies to give the best chance of reducing macrovascular complications in the long term.

Chapter 14 Case 5: A patient diagnosed with diabetes mellitus after comprehensive prosthodontic rehabilitation Ira B. Lamster DDS, MMSc, Ira B. Lamster DDS, MMScSearch for more papers by this authorNurit Bittner DDS, MS, Nurit Bittner DDS, MSSearch for more papers by this authorDaniel Lorber MD, Daniel Lorber MDSearch for more papers by this author Ira B. Lamster DDS, MMSc, Ira B. Lamster DDS, MMScSearch for more papers by this authorNurit Bittner DDS, MS, Nurit Bittner DDS, MSSearch for more papers by this authorDaniel Lorber MD, Daniel Lorber MDSearch for more papers by this author Book Editor(s):Ira B. Lamster, Ira B. LamsterSearch for more papers by this author First published: 28 March 2014 https://doi.org/10.1002/9781118887837.ch14 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onFacebookTwitterLinked InRedditWechat Summary This chapter presents a case study that a patient who was restored with implants and fixed partial dentures three years ago now presents to the dental office with significant dental problems. Recently diagnosed with diabetes mellitus, the history suggests the metabolic syndrome was present before the development of diabetes mellitus. The chapter presents medical history, dental history and history of the current problem, treatment plan, and treatment for the patient. Diabetes Mellitus and Oral Health: An Interprofessional Approach RelatedInformation

A t any given time, over 2 million people are incarcerated in prisons and jails in the U.S (1). It is estimated that nearly 80,000 of these inmates have diabetes, a prevalence of 4.8% (2). In addition, many more people pass through the corrections system in a given year. In 1998 alone, over 11 million people were released from prison to the community (1). The current estimated prevalence of diabetes in correctional institutions is somewhat lower than the overall U.S. prevalence of diabetes, perhaps because the incarcerated population is younger than the general population. The prevalence of diabetes and its related comorbidities and complications, however, will continue to increase in the prison population as current sentencing guidelines continue to increase the number of aging prisoners and the incidence of diabetes in young people continues to increase. People with diabetes in correctional facilities should receive care that meets national standards. Correctional institutions have unique circumstances that need to be considered so that all standards of care may be achieved (3). Correctional institutions should have written policies and procedures for the management of diabetes and for training of medical and correctional staff in diabetes care practices. These policies must take into consideration issues such as security needs, transfer from one facility to another, and access to medical personnel and equipment, so that all appropriate levels of care are provided. Ideally, these policies should encourage or at least allow patients to self-manage their diabetes. Ultimately, diabetes management is dependent upon having access to needed medical personnel and equipment. Ongoing diabetes therapy is important in order to reduce the risk of later complications, including cardiovascular events, visual loss, renal failure, and amputation. Early identification and intervention for people with diabetes is also likely to reduce short-term risks for acute complications requiring transfer out of the facility, thus improving security. This document provides a general set of guidelines for diabetes care in correctional institutions. It is not designed to be a diabetes management manual. More detailed information on the management of diabetes and related disorders can be found in the American Diabetes Association (ADA)Clinical Practice Recommendations, published each year in January as the first supplement to Diabetes Care, as well as the “Standards ofMedical Care in Diabetes” (4) contained therein. This discussion will focus on those areas where the care of people with diabetes in correctional facilities may differ, and specific recommendations are made at the end of each section.

Questions are sometimes raised by employers about the safety and effectiveness of individuals with diabetes in a given job. When such questions are legitimately raised, a personwith diabetes should be individually assessed to determinewhether or not that person can safely and effectively perform the particular duties of the job in question. This document provides a general set of guidelines for evaluating individuals with diabetes for employment, including how an assessment should be performed and what changes (accommodations) in the workplace may be needed for an individual with diabetes.

Of the nearly 19 million people in the U.S. with diagnosed diabetes (1), a large percentage will seek or currently hold a license to drive. For many, a driver’s license is essential to work; taking care of family; securing access to public and private facilities, services, and institutions; interacting with friends; attending classes; and/ or performing many other functions of daily life. Indeed, in many communities and areas of the U.S. the use of an automobile is the only (or the only feasible or affordable) means of transportation available.