Making Sense of the Nonalcoholic Fatty Liver Disease Clinical Practice Guidelines: What Clinicians Need to Know.

Standards of care summarized in clinical practice guidelines for nonalcoholic fatty liver disease (NAFLD) offer clinicians a streamlined diagnostic and management approach based on the best available evidence. These recommendations have changed a great deal in recent years; today, there is a clear focus on screening for the early identification and risk stratification of patients at high risk of steatohepatitis and clinically significant fibrosis to promote timely referrals to specialty care when needed. This article reviews and provides the rationale for current guidelines for NAFLD screening, diagnosis, treatment, and monitoring and addresses barriers to providing evidence-based NAFLD care and how to overcome them. The current paradigm of care calls for primary care clinicians and specialists to work together, within a multidisciplinary care team familiar with obesity and diabetes care, to provide comprehensive management of these complex patients.

Community-Based Diabetes Awareness Strategy With Detection and Intervention: The Mobile Diabetes Education Center.

To prevent diabetes and increase equitable access to health care screenings, Touro University California has created and implemented a community outreach program called the Mobile Diabetes Education Center (MOBEC). This program is a joint effort that also involves Sutter Health, the California Department of Public Health, Kaiser Permanente, the Solano County Department of Public Health, and community-based organizations, focusing on advancing health equity in Solano County's at-risk populations. This article reports on the services and initial successes of MOBEC. With its strong community collaboration, MOBEC has helped to raise awareness of diabetes and ensure access to much-needed health screenings and education. This model can potentially be used as a blueprint for similar efforts nationwide to address the health care needs of medically underserved communities.

Nonalcoholic fatty liver disease from a primary care perspective.

Nonalcoholic fatty liver disease (NAFLD) affects up to one-third of the US population. Approximately one-fifth of patients with NAFLD have nonalcoholic steatohepatitis (NASH), characterized by hepatocyte damage and inflammation with or without fibrosis. NASH leads to greater risk of liver-related complications and liver-related mortality, with the poorest outcomes seen in patients with advanced fibrosis. NASH is also associated with other metabolic comorbidities and conveys an increased risk of adverse cardiovascular outcomes and extrahepatic cancers. Despite its high prevalence, NAFLD is frequently underdiagnosed. This is a significant concern, given that early diagnosis of NAFLD is a key step in preventing progression to NASH. In this review, we describe the clinical impact of NASH from the perspective of both the clinician and the patient. In addition, we provide practical guidance on the diagnosis and management of NASH for primary care providers, who play a pivotal role in the frontline care of patients with NASH, and we use case studies to illustrate real-world scenarios encountered in the primary care setting.

Preparing for the NASH Epidemic: A Call to Action.

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common conditions with a rising burden. Yet there are significant management gaps between clinical guidelines and practice in patients with NAFLD and NASH. Further, there is no single global guiding strategy for the management of NAFLD and NASH. The American Gastroenterological Association, in collaboration with 7 professional associations, convened an international conference comprising 32 experts in gastroenterology, hepatology, endocrinology, and primary care providers from the United States, Europe, Asia, and Australia. Conference content was informed by the results of a national NASH Needs Assessment Survey. The participants reviewed and discussed published literature on global burden, screening, risk stratification, diagnosis, and management of individuals with NAFLD, including those with NASH. Participants identified promising approaches for clinical practice and prepared a comprehensive, unified strategy for primary care providers and relevant specialists encompassing the full spectrum of NAFLD/NASH care. They also identified specific high-yield targets for clinical research and called for a unified, international public health response to NAFLD and NASH.

Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease.

Find AGA's NASH Clinical Care Pathway App for iOS and Android mobile devices at nash.gastro.org. Scan this QR code to be taken directly to the website.Nonalcoholic fatty liver disease (NAFLD) is becoming increasingly common, currently affecting approximately 37% of US adults. NAFLD is most often managed in primary care or endocrine clinics, where clinicians must determine which patients might benefit from secondary care to address hepatic manifestations, comorbid metabolic traits, and cardiovascular risks of the disease. Because NAFLD is largely asymptomatic, and because optimal timing of treatment depends on accurate staging of fibrosis risk, screening at the primary care level is critical, together with consistent, timely, evidence-based, widely accessible, and testable management processes. To achieve these goals, the American Gastroenterological Association assembled a multidisciplinary panel of experts to develop a Clinical Care Pathway providing explicit guidance on the screening, diagnosis, and treatment of NAFLD. This article describes the NAFLD Clinical Care Pathway they developed and provides a rationale supporting proposed steps to assist clinicians in diagnosing and managing NAFLD with clinically significant fibrosis (stage F2-F4) based on the best available evidence. This Pathway is intended to be applicable in any setting where care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.

Real and Perceived Discordance in Physicians and U.S. Adults' Beliefs Regarding the Causes and Controllability of Type 2 Diabetes.

Discordance between physicians and patients' health beliefs can impede health communication efforts. However, little research considers physicians' perceptions of patient beliefs, despite the importance of perceptions in shaping communication. In the current work, we examine instances of actual and perceived discordance between physicians and U.S. adults' beliefs regarding the causes and controllability of type 2 diabetes. 229 family physicians completed an online survey measuring their health beliefs and perceptions of their patients' beliefs. Physicians' responses were contrasted against beliefs from a national survey sample of 1,168 U.S. adults. T-tests assessed whether (a) physicians' beliefs diverged from the national sample's beliefs (actual discordance), (b) physicians perceived that their health beliefs diverged from their patients' beliefs (perceived discordance), and (c) physicians' perceptions of patient beliefs diverged from the national sample's beliefs (accuracy of perceived discordance). Findings revealed evidence of actual discordance; compared to the national sample, physicians were more likely to attribute type 2 diabetes to genes (versus lifestyle factors) and perceived greater control over developing diabetes. Moreover, although physicians perceived discordance between their own and their patients' beliefs, data from the national sample suggested that these gaps were less substantial than physicians expected. In particular, findings showed that physicians generally overestimated discordance, expecting that people would be less likely to (1) attribute the development of diabetes to lifestyle factors (versus genes), and (2) perceive control over developing diabetes, than was actually reported. Implications of actual and perceived discordance for effective health communication and patient education are discussed.

Pharmacologic Approaches to Glycemic Treatment of Type 2 Diabetes: Synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical Guideline.

DESCRIPTION: The American Diabetes Association (ADA) updates the Standards of Medical Care in Diabetes annually to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of diabetes. METHODS: To develop the 2020 Standards, the ADA Professional Practice Committee, comprising physicians, adult and pediatric endocrinologists, diabetes educators, registered dietitians, epidemiologists, pharmacists, and public health experts, continuously searched MEDLINE (English language only) from 15 October 2018 through August-September 2019 for pertinent studies, including high-quality trials that addressed pharmacologic management of type 2 diabetes. The committee selected and reviewed the studies, developed the recommendations, and solicited feedback from the larger clinical community. RECOMMENDATIONS: This synopsis focuses on guidance relating to the pharmacologic treatment of adults with type 2 diabetes. Recommendations address oral and noninsulin injectable therapies, insulin treatment, and combination injectable therapies. Results of recent large trials with cardiovascular and renal outcomes are emphasized.

Primary Care Diabetes Fellowship Programs: Developing National Standards.

The rapid and constant increase in the number of people living with diabetes has outstripped the capacity of specialists to fully address this chronic disease alone. Furthermore, although most people with diabetes are treated in the primary care setting, most primary care providers feel under-prepared and under-resourced to fully address the needs of their patients with diabetes. Addressing this care gap will require a multifaceted approach centering on primary care training in diabetes and its complications. One-year diabetology fellowship programs are well situated to provide this training. Previous research has shown that the higher the diabetes-specific volume of patients seeing a primary care physician was, the better the quality outcomes were across six quality indicators (eye examinations, LDL cholesterol testing, A1C testing, prescriptions for ACE inhibitors or angiotensin receptor blockers, prescriptions for statins, and emergency department visits for hypoglycemia or hyperglycemia). Primary care diabetes fellowships have existed for many years, but the number of fellowships and fellowship positions has recently grown dramatically. This article proposes a standardized curriculum for such programs and makes the case for increasing their number in the United States.

Erratum. Diabetic Gastroparesis: A Review. Diabetes Spectrum 2020;33:290-297 (https://doi.org/10.2337/ds19-0062).

[This corrects the article on p. 290 in vol. 33, PMID: 32848351.].

Review of Associations Between Type 2 Diabetes and Cancer.

Debate is ongoing regarding the relationship between type 2 diabetes and cancer, and the pathways linking the two are incompletely understood. Some posit that the relationship hinges on a common predisposing factor such as obesity, insulin resistance, or chronic inflammation that increases the risk of cancer independently. Others speculate that diabetes acts as an independent risk factor for cancer because of other molecular pathways and interactions. Additionally, antidiabetic medications have been associated with changes in cancer risk. This review presents a summary of the latest studies and data concerning the relationships among type 2 diabetes, antidiabetic medications, cancer risk, and cancer prognosis.

Patients With Type 2 Diabetes Are Willing to Do More to Overcome Therapeutic Inertia: Results From a Double-Blind Survey.

We performed a survey of 305 patients with type 2 diabetes receiving basal insulin and 240 physicians to measure key contrasts and similarities in patients' preferences and providers' beliefs and perceptions regarding insulin use. Many patients reported being more frustrated with their lack of treatment progress than physicians were aware of. Patients were also more likely to say they would do more than their physicians believed they would to better manage their diabetes. Identifying priorities and setting clear goals and timelines for achieving glycemic control could provide an opportunity to address these differences and reduce patients' frustration.

Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018.

Description: The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendations: This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.

A visual interactive analytic tool for filtering and summarizing large health data sets coded with hierarchical terminologies (VIADS).

BACKGROUND: Vast volumes of data, coded through hierarchical terminologies (e.g., International Classification of Diseases, Tenth Revision-Clinical Modification [ICD10-CM], Medical Subject Headings [MeSH]), are generated routinely in electronic health record systems and medical literature databases. Although graphic representations can help to augment human understanding of such data sets, a graph with hundreds or thousands of nodes challenges human comprehension. To improve comprehension, new tools are needed to extract the overviews of such data sets. We aim to develop a visual interactive analytic tool for filtering and summarizing large health data sets coded with hierarchical terminologies (VIADS) as an online, and publicly accessible tool. The ultimate goals are to filter, summarize the health data sets, extract insights, compare and highlight the differences between various health data sets by using VIADS. The results generated from VIADS can be utilized as data-driven evidence to facilitate clinicians, clinical researchers, and health care administrators to make more informed clinical, research, and administrative decisions. We utilized the following tools and the development environments to develop VIADS: Django, Python, JavaScript, Vis.js, Graph.js, JQuery, Plotly, Chart.js, Unittest, R, and MySQL. RESULTS: VIADS was developed successfully and the beta version is accessible publicly. In this paper, we introduce the architecture design, development, and functionalities of VIADS. VIADS includes six modules: user account management module, data sets validation module, data analytic module, data visualization module, terminology module, dashboard. Currently, VIADS supports health data sets coded by ICD-9, ICD-10, and MeSH. We also present the visualization improvement provided by VIADS in regard to interactive features (e.g., zoom in and out, customization of graph layout, expanded information of nodes, 3D plots) and efficient screen space usage. CONCLUSIONS: VIADS meets the design objectives and can be used to filter, summarize, compare, highlight and visualize large health data sets that coded by hierarchical terminologies, such as ICD-9, ICD-10 and MeSH. Our further usability and utility studies will provide more details about how the end users are using VIADS to facilitate their clinical, research or health administrative decision making.

Food Insecurity Is Associated With Poorer Glycemic Control in Patients Receiving Free Versus Fee-Based Care.

IN BRIEF This study examined differences in household food security (HFS), household adult food security (HAFS), and indicators of diabetes management between clients using free and fee-for-service clinics for diabetes care and management. The study's 166 participants (free clinic, n = 41; fee-for-service clinic, n =125) had a mean age of 53 ± 16 years and were primarily Caucasian (n = 147 [91.9%]). Both HFS (P <0.001) and HAFS (P <0.001) differed between the clinic groups, as did A1C (free clinic 8.7 ± 1.7%; fee-for-service 7.8 ± 1.6%; P = 0.005). A1C increased as HFS (r = 0.293, P <0.001) and HAFS (r = 0.288, P = 0.001) worsened.

Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

DESCRIPTION: The American Diabetes Association (ADA) annually updates the Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. METHODS: For the 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. RECOMMENDATIONS: This synopsis focuses on recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

DESCRIPTION: The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. METHODS: For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. RECOMMENDATION: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

Time Needed for Diabetes Self-Care: Nationwide Survey of Certified Diabetes Educators.

PURPOSE: To approximate the time required for self-care of individuals with diabetes, as estimated by certified diabetes educators (CDEs). METHODS: A survey was sent to the CDE member list of the American Association of Diabetes Educators (AADE). The survey asked the CDEs to estimate the time in minutes/day needed for 1) each component of diabetes self-care and 2) all components of diabetes management as recommended by the American Diabetes Association and AADE. Estimates were for two sample patients: 1) an adult with type 2 diabetes (for at least 1 year) on oral medications who performs self-monitoring of blood glucose (SMBG) twice daily and 2) a school-age child with established type 1 diabetes (for at least 1 year) who takes four insulin injections per day and has SMBG four times daily. RESULTS: A total of 674 CDEs completed and returned the survey. The mean times needed for an adult with type 2 diabetes for routine, daily diabetes self-management and for all recommended components of self-care were estimated to be 66 and 234 minutes, respectively. The mean times needed for a child with type 1 diabetes for routine, daily diabetes self-management and for all recommended components of self-care were estimated to be 78 and 305 minutes, respectively. CONCLUSION: The total estimated time needed daily for recommended diabetes self-care was ~4 hours for adults and >5 hours for children-far more than is reasonably feasible for most people with diabetes. This information should be considered when helping patients with diabetes achieve self-care goals.