Christine A. Beebe

Bio: Christine A. Beebe is an academic researcher. The author has contributed to research in topics: Evidence-based practice & Scientific evidence. The author has an hindex of 4, co-authored 4 publications receiving 1879 citations.

Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications

Abstract: Historically, nutrition principles and recommendations for diabetes and related complications have been based on scientific evidence and diabetes knowledge when available and, when evidence was not available, on clinical experience and expert consensus. Often it has been difficult to discern the level of evidence used to construct the nutrition principles and recommendations. Furthermore, in clinical practice, many nutrition recommendations that have no scientific supporting evidence have been and are still being given to individuals with diabetes. To address these problems and to incorporate the research done in the past 8 years, this 2002 technical review provides principles and recommendations classified according to the level of evidence available. It reviews the evidence from randomized, controlled trials; cohort and case-controlled studies; and observational studies, which can also provide valuable evidence (1,2), and takes into account the number of studies that have provided consistent outcomes of support. In this review, nutrition principles are graded into four categories based on the available evidence: those with strong supporting evidence, those with some supporting evidence, those with limited supporting evidence and those based on expert consensus. Evidence-based nutrition recommendations attempt to translate research data and clinically applicable evidence into nutrition care. However, the best available evidence must still be moderated by individual circumstances and preferences. The goal of evidence-based recommendations is to improve the quality of clinical judgments and facilitate cost-effective care by increasing the awareness of clinicians and patients with diabetes of the evidence supporting nutrition services and the strength of that evidence, both in quality and quantity. Before 1994, the American Diabetes Association’s (ADA’s) nutrition principles and recommendations attempted to define an “ideal” nutrition prescription that would apply to everyone with diabetes (3,4,5). Although individualization was a major principle of all recommendations, it was usually done within defined …

Nutrition principles and recommendations in diabetes.

Abstract: M edical nutrition therapy is an integral component of diabetes management and of diabetes selfmanagement education. Yet many misconceptions exist concerning nutrition and diabetes. Moreover, in clinical practice, nutrition recommendations that have little or no supporting evidence have been and are still being given to persons with diabetes. Accordingly, this position statement provides evidence-based principles and recommendations for diabetes medical nutrition therapy. The rationale for this position statement is discussed in the American Diabetes Association technical review “Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications,” which discusses in detail the published research for each principle and recommendation (1). Historically, nutrition recommendations for diabetes and related complications were based on scientific knowledge, clinical experience, and expert consensus; however, it was often difficult to discern the level of evidence used to construct the recommendations. To address this problem, the 2002 technical review (1) and this position statement provide principles and recommendations classified according to the level of evidence available using the American Diabetes Association evidence grading system. However, the best available evidence must still take into account individual circumstances, preferences, and cultural and ethnic preferences, and the person with diabetes should be involved in the decision-making process. The goal of evidence-based recommendations is to improve diabetes care by increasing the awareness of clinicians and persons with diabetes about beneficial nutrition therapies. Because of the complexity of nutrition issues, it is recommended that a registered dietitian, knowledgeable and skilled in implementing nutrition therapy into diabetes management and education, be the team member providing medical nutrition therapy. However, it is essential that all team members be knowledgeable about nutrition therapy and supportive of the person with diabetes who needs to make lifestyle changes.

Nutrition principles for the management of diabetes and related complications.

Abstract: Health professionals and people with diabetes recognize nutrition therapy as one of the most challenging aspects of diabetes care and education (1). Adherence to meal planning principles requires the person with diabetes to learn specific nutrition recommendations. It may require altering previous patterns of eating and implementing new eating behaviors, which requires motivation for a healthy lifestyle and may also require participation in exercise programs. Finally, individuals must be able to evaluate the effectiveness of these lifestyle changes. Despite these challenges, nutrition is an essential component of successful diabetes management.

American diabetes association position statement: evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications

Abstract: Medical nutrition therapy for people with diabetes should be individualized, with consideration given to the individual's usual food and eating habits, metabolic profile, treatment goals and desired outcomes. Monitoring of metabolic parameters, including glucose, HbA1c, lipids, blood pressure, body weight, and renal function, when appropriate, as well as quality of life is essential to assess the need for changes in therapy and ensure successful outcomes. Ongoing nutrition self-management education and care needs to be available for individuals with diabetes. Additionally many areas of nutrition and diabetes require additional research.

Standards of Medical Care in Diabetes—2012

Abstract: D iabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. Specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A large number of these interventions have been shown to be cost-effective (4). A grading system (Table 1), developed by the American Diabetes Association (ADA) andmodeled after existingmethods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence. For the current revision, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010. Recommendations (bulleted at the beginning of each subsection and also listed in the “Executive Summary: Standards of Medical Care in Diabetesd2012”) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http:// professional.diabetes.org/CPR_Search. aspx. Subsequently, as is the case for all Position Statements, the standards of care were reviewed and approved by the ExecutiveCommittee of ADA’s Board ofDirectors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical community was valuable for the 2012 revision of the standards. Readers who wish to comment on the “Standards of Medical Care in Diabetesd2012” are invited to do so at http://professional.diabetes.org/ CPR_Search.aspx. Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the standards revisionmeeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional PracticeCommitteeMembers” table (see pg. S109). The AmericanDiabetes Association funds development of the standards and all its position statements out of its general revenues and does not utilize industry support for these purposes.

Standards of Medical Care in Diabetes—2010

Abstract: D iabetes is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was used to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA multidisciplinary Professional Practice Committee, and new evidence is incorporated. Members of the Professional Practice Committee and their disclosed conflicts of interest are listed in the Introduction. Subsequently, as with all position statements, the standards of care are reviewed and approved by the Executive Committee of ADA’s Board of Directors.

Standards of Medical Care in Diabetes—2011

Abstract: I. CLASSIFICATION AND DIAGNOSIS OF DIABETES, p. S12 A. Classification of diabetes B. Diagnosis of diabetes C. Categories of increased risk for diabetes (prediabetes) II. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS, p. S13 A. Testing for type 2 diabetes and risk of future diabetes in adults B. Testing for type 2 diabetes in children C. Screening for type 1 diabetes III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS, p. S15 IV. PREVENTION/DELAY OF TYPE 2 DIABETES, p. S16 V. DIABETES CARE, p. S16 A. Initial evaluation B. Management C. Glycemic control 1. Assessment of glycemic control a. Glucose monitoring b. A1C 2. Glycemic goals in adults D. Pharmacologic and overall approaches to treatment 1. Therapy for type 1 diabetes 2. Therapy for type 2 diabetes E. Diabetes self-management education F. Medical nutrition therapy G. Physical activity H. Psychosocial assessment and care I. When treatment goals are not met J. Hypoglycemia K. Intercurrent illness L. Bariatric surgery M. Immunization VI. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS, p. S27 A. Cardiovascular disease 1. Hypertension/blood pressure control 2. Dyslipidemia/lipid management 3. Antiplatelet agents 4. Smoking cessation 5. Coronary heart disease screening and treatment B. Nephropathy screening and treatment C. Retinopathy screening and treatment D. Neuropathy screening and treatment E. Foot care VII. DIABETES CARE IN SPECIFIC POPULATIONS, p. S38 A. Children and adolescents 1. Type 1 diabetes Glycemic control a. Screening and management of chronic complications in children and adolescents with type 1 diabetes i. Nephropathy ii. Hypertension iii. Dyslipidemia iv. Retinopathy v. Celiac disease vi. Hypothyroidism b. Self-management c. School and day care d. Transition from pediatric to adult care 2. Type 2 diabetes 3. Monogenic diabetes syndromes B. Preconception care C. Older adults D. Cystic fibrosis–related diabetes VIII. DIABETES CARE IN SPECIFIC SETTINGS, p. S43 A. Diabetes care in the hospital 1. Glycemic targets in hospitalized patients 2. Anti-hyperglycemic agents in hospitalized patients 3. Preventing hypoglycemia 4. Diabetes care providers in the hospital 5. Self-management in the hospital 6. Diabetes self-management education in the hospital 7. Medical nutrition therapy in the hospital 8. Bedside blood glucose monitoring 9. Discharge planning IX. STRATEGIES FOR IMPROVING DIABETES CARE, p. S46

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

Abstract: ContextClinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population); the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her $406 per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.