The correct answer is c. According to the American Diabetes Association, initial testing for diabetes should be considered in all individuals at age 45 and above, particularly in those with a body mass index ≥25 and if normal should be repeated every 3 years. Testing would occur at a younger age or more frequently in people who are overweight (BMI ≥25) and have additional risk factors - e.g. are habitually physically inactive; have first degree relatives with diabetes; are members of a high-risk population (African American, Latino, Native American, Asian American, or Pacific Islander); have delivered a baby weighing >9 lb or have been diagnosed with GDM; are hypertensive (≥140/90 mmHg); have an HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l); have polycystic ovarian syndrome (PCOS); on previous testing had glucose intolerance; have other clinical conditions associated with insulin resistance (acanthosis nigricans); or have a history of vascular disease. Mr. Big is overweight but has none of these additional risk factors thus he should be screened every three years.
The correct answer is c. A low-carbohydrate, high protein diet is not recommended for Ms. Bradshaw. Although weight loss will contribute to better diabetic control, low-carbohydrate diets are not recommended for diabetic patients because restricting carbohydrates below 130 grams / day may be below brain, nervous system, and other metabolic requirements. It is unclear as to how these low-carbohydrate, high protein diets affect renal function in diabetic patients without renal disease. In diabetic patients with any degree of chronic kidney disease, protein intake should be reduced to recommended daily allowance of 0.8 g / kg. Low-carbohydrate diets will reduce post-prandial carbohydrates load for diabetic patients but at risk of severe hypoglycemia.
The correct answer is b. Serum creatinine should NOT be used alone to measure renal function in diabetic patients. In diabetic nephropathy, the reduced function of dying nephrons are compensated by the increasing function of the remaining healthy nephrons thus making the serum creatinine appear normal over time, although renal disease may already present. All type 2 diabetes patients should be screened annually for random urine microalbumin starting at diagnosis. In addition, serum creatinine should be measured annually to calculate the glomerular filtration rate in all patients with diabetes regardless of microalbuminuria to measure the stage of renal function. This can be done via the MDRD (Modification of Diet in Renal Disease) GFR equation which is the most accurate equation taking into account age, sex, and race factors. In diabetic patients with hypertension and microalbuminuria, ACE inhibitors and ARBs (angiotensin receptor blockers) have been shown to delay progression to macroalbuminuria.
The correct answer is b. Quality is defined as meeting and / or exceeding the expectations of patients, families, and communities. Most problems are found in system processes, not in individual people. Continuous quality improvement does not seek to blame but improve processes. Unintended variation in processes can lead to unwanted variation in outcomes, and therefore the point is to seek to reduce or eliminate unwanted variation. Continual improvement can be achieved through small, incremental changes using the scientific method. Continuous improvement is most effective when it becomes a natural part of the way everyday work is done and not a peripheral periodic activity. Success is achieved through meeting the needs of those served – the patients, their families, and their communities – not the needs of physicians or health providers.
The correct answer is d. At this current time, there is increasing body of research that shows that pre-diabetic patients may limit progression to type 2 diabetes by using glitazones and metformin that target insulin resistance, but cost effectiveness has not yet been demonstrated. Therefore drug therapy is not recommended for preventing diabetes at this time. Pre-diabetic patients should be counseled on both the benefits of modest weight loss (5 – 7% loss of body weight) and increasing physical activity. Weight loss and regular exercise can reduce the risk of diabetes by almost 50%. Patients with pre-diabetes are usually asymptomatic and should be monitored for the development of diabetes every 1 – 2 years.