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DOI: 10.2337/dc08-S012
© 2008 by the American Diabetes Association
Position Statements |
Standards of Medical Care in Diabetes—2008
Abbreviations: ABI, ankle-brachial index • ACE, angiotensin-converting enzyme • ADAG, A1C-Derived Average Glucose • ARB, angiotensin receptor blocker • CAD, coronary artery disease • CBG, capillary blood glucose • CHD, coronary heart disease • CHF, congestive heart failure • CKD, chronic kidney disease • CMS, Centers for Medicare and Medicaid Services • CSII, continuous subcutaneous insulin infusion • CVD, cardiovascular disease • DCCT, Diabetes Control and Complications Trial • DKA, diabetic ketoacidosis • DMMP, diabetes medical management plan • DPN, distal symmetric polyneuropathy • DPP, Diabetes Prevention Program • DRS, Diabetic Retinopathy Study • DSME, diabetes self-management education • DSMT, diabetes self-management training • eAG, estimated average glucose • ECG, electrocardiogram • EDIC, Epidemiology of Diabetes Interventions and Complications • ERP, education recognition program • ESRD, end-stage renal disease • ETDRS, Early Treatment Diabetic Retinopathy Study • FDA, Food and Drug Administration • FPG, fasting plasma glucose • GDM, gestational diabetes mellitus • GFR, glomerular filtration rate • ICU, intensive care unit • IFG, impaired fasting glucose • IGT, impaired glucose tolerance • MICU, medical ICU • MNT, medical nutrition therapy • NDEP, National Diabetes Education Program • NPDR, nonproliferative diabetic retinopathy • OGTT, oral glucose tolerance test • PAD, peripheral arterial disease • PDR, proliferative diabetic retinopathy • PPG, postprandial plasma glucose • RAS, renin-angiotensin system • RDA, recommended dietary allowance • SICU, surgical ICU • SMBG, self-monitoring of blood glucose • TSH, thyroid-stimulating hormone • TZD, thiazolidinedione • UKPDS, U.K. Prospective Diabetes Study
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INTRODUCTION |
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Diabetes is a chronic illness that requires continuing medical care and patient self-management education 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, 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 more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to refs. 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 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.
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I. CLASSIFICATION AND DIAGNOSIS |
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A. Classification
In 1997, ADA issued new diagnostic and classification criteria (4); in 2003, modifications were made regarding the diagnosis of impaired fasting glucose (5). The classification of diabetes includes four clinical classes:
- Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency)
- Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance)
- Other specific types of diabetes due to other
. . . [Full Text of this Article]
Recommendations
C. Diagnosis of pre-diabetes
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II. TESTING FOR PRE-DIABETES AND DIABETES IN ASYMPTOMATIC PATIENTS |
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Recommendations
A. Testing for pre-diabetes and type 2 diabetes in adults
B. Testing for type 2 diabetes in children
C. Screening for type 1 diabetes
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III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS (GDM) |
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Recommendations
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IV. PREVENTION/DELAY OF TYPE 2 DIABETES |
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Recommendations
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V. DIABETES CARE |
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A. Initial evaluation
B. Management
C. Glycemic control
1. Assessment of glycemic control.
a. Self-monitoring of blood glucose
Recommendations
b. A1C
Recommendations
2. Glycemic goals
Recommendations
3. Approach to treatment
a. Therapy for type 1 diabetes.
b. Therapy for type 2 diabetes.
D. Medical Nutrition Therapy (MNT)
General recommendations
Energy balance, overweight, and obesity
Primary prevention of diabetes
Dietary fat intake in diabetes management
Carbohydrate intake in diabetes management
Other nutrition recommendations
Reimbursement for MNT
E. DSME
Recommendations
Evidence for the benefits of DSME
The National Standards for DSME
Reimbursement for DSME
F. Physical activity
Recommendations
Frequency and type of exercise
Evaluation of the diabetic patient before recommending an exercise program
Exercise in the presence of nonoptimal glycemic control
Hyperglycemia.
Hypoglycemia.
Exercise in the presence of specific long-term complications of diabetes
Retinopathy.
Peripheral neuropathy.
Autonomic neuropathy.
Albuminuria and nephropathy.
G. Psychosocial assessment and care
Recommendations
H. When treatment goals are not met
I. Intercurrent illness
J. Hypoglycemia
Recommendations
K. Immunization
Recommendations
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VI. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS |
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A. CVD
1. Hypertension/blood pressure control
Recommendations
Screening and diagnosis
Goals
Treatment
Screening and diagnosis
Treatment goals
Treatment strategies
2. Dyslipidemia/lipid management
Recommendations
Screening
Treatment recommendations and goals
Evidence for benefits of lipid-lowering therapy
Dyslipidemia treatment and target lipid levels
Alternative LDL cholesterol goals
Treatment of other lipoprotein fractions
3. Antiplatelet agents
Recommendations
4. Smoking cessation
Recommendations
5. CHD screening and treatment
Recommendations
Screening
Treatment
B. Nephropathy screening and treatment
Recommendations
General recommendations
Screening
Treatment
Assessment of albuminuria status and renal function
C. Retinopathy screening and treatment
Recommendations
General recommendations
Screening
Treatment
D. Neuropathy screening and treatment
Recommendations
Diagnosis of neuropathy
Distal symmetric polyneuropathy
Diabetic autonomic neuropathy
Symptomatic treatments
DPN
Treatment of autonomic neuropathy
E. Foot care
Recommendations
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VII. DIABETES CARE IN SPECIFIC POPULATIONS |
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A. Children and adolescents
1. Type 1 diabetes
a. Glycemic control
Recommendations
b. Screening and management of chronic complications in children and adolescents with type 1 diabetes
i. Nephropathy
Recommendations
ii. Hypertension
Recommendations
iii. Dyslipidemia
Recommendations
Screening
Treatment
iv. Retinopathy
Recommendations
v. Celiac disease
Recommendations
vi. Hypothyroidism
Recommendations
c. "Adherence"
d. School and day care.
2. Type 2 diabetes
B. Preconception care
Recommendations
C. Older adults
Recommendations
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VIII. DIABETES CARE IN SPECIFIC SETTINGS |
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A. Diabetes care in the hospital
Recommendations
1. In-hospital hyperglycemia and outcomes
a. General medicine and surgery.
b. CVD and critical care.
c. Cardiac surgery.
d. Critical care.
2. Glycemic targets in hospitalized patients
3. Treatment options in hospitalized patients
a. Noninsulin glucose-lowering agents.
b. Insulin
i. Subcutaneous insulin therapy.
ii. Intravenous insulin infusion.
iii. Transition from intravenous to subcutaneous insulin therapy.
4. Self-management in the hospital
5. Preventing hypoglycemia
6. Diabetes care providers in the hospital
7. DSME in the hospital
8. MNT in the hospital
9. Bedside blood glucose monitoring
10. Continuous blood glucose monitoring in the hospital
B. Diabetes care in the school and day care setting
Recommendations
C. Diabetes care at diabetes camps
Recommendations
D. Diabetes management in correctional institutions
Recommendations
E. Emergency and disaster preparedness
Recommendations
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IX. HYPOGLYCEMIA AND EMPLOYMENT/LICENSURE |
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Recommendations
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X. THIRD-PARTY REIMBURSEMENT FOR DIABETES CARE, SELF-MANAGEMENT EDUCATION, AND SUPPLIES |
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Recommendations
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XI. STRATEGIES FOR IMPROVING DIABETES CARE |
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