Standards of Medical Care in Diabetes 2011

7/28/2019 Standards of Medical Care in Diabetes 2011

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POSITIONSTATEMENT

StandardsofMedicalCareinDiabetes2011

AMERICANDIABETESASSOCIATION

CONTENTS

I.CLASSIFICATIONANDDIAGNOSIS

OFDIABETES,p.S12A.ClassificationofdiabetesB.DiagnosisofdiabetesC.

Categoriesofincreasedriskfordiabetes(prediabetes)II.TESTINGFORDIABETESINASYMPTOMATIC

PATIENTS,p.S13A.Testingfortype2diabetesand


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riskoffuturediabetesinadultsB.Testingfortype2diabetesinchildrenC.Screeningfortype1diabetesIII.DETECTIONANDDIAGNOSIS

OFGESTATIONALDIABETESMELLITUS,p.S15IV.PREVENTION/DELAYOFTYPE2DIABETES,p.

S16V.DIABETESCARE,p.S16A.InitialevaluationB.ManagementC.Glycemic

control1.Assessmentofglycemiccontrola.Glucosemonitoringb.


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A1C2.GlycemicgoalsinadultsD.Pharmacologicandoverallapproachestotreatment1.Therapyfortype1diabetes2.Therapyfortype2

diabetesE.Diabetesself-managementeducationF.MedicalnutritiontherapyG.PhysicalactivityH.

PsychosocialassessmentandcareI.WhentreatmentgoalsarenotmetJ.Hypoglycemia

K.IntercurrentillnessL.BariatricsurgeryM.ImmunizationVI.PREVENTION


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ANDMANAGEMENTOFDIABETESCOMPLICATIONS,p.S27A.Cardiovasculardisease1.Hypertension/bloodpressurecontrol2.Dyslipidemia/lipidmanagement3.Antiplateletagents4.Smokingcessation5.

CoronaryheartdiseasescreeningandtreatmentB.NephropathyscreeningandtreatmentC.Retinopathy

screeningandtreatmentD.NeuropathyscreeningandtreatmentE.FootcareVII.DIABETES

CAREINSPECIFICPOPULATIONS,p.S38A.Childrenandadolescents


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1.Type1diabetesGlycemiccontrola.Screeningandmanagementofchroniccomplicationsinchildrenandadolescentswithtype1diabetesi.Nephropathyii.

Hypertensioniii.Dyslipidemiaiv.Retinopathyv.Celiacdiseasevi.Hypothyroidismb.Self-managementc.

Schoolanddaycared.Transitionfrompediatrictoadultcare2.Type

2diabetes3.MonogenicdiabetessyndromesB.PreconceptioncareC.


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OlderadultsD.CysticfibrosisrelateddiabetesVIII.DIABETESCAREINSPECIFICSETTINGS,p.S43A.Diabetescareinthehospital1.Glycemictargetsin

hospitalizedpatients2.Anti-hyperglycemicagentsinhospitalizedpatients3.PreventinghypoglycemiaOriginallyapproved

1988.Mostrecentreview/revisionOctober2010.

DOI:10.2337/dc11-S011

2011bytheAmericanDiabetesAssociation.Readersmayusethis


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articleaslongastheworkisproperlycited,theuseiseducationalandnotforprofit,andtheworkisnotaltered.See

http://creativecommons.org/licenses/by-nc-nd/3.0/fordetails.

4.Diabetescareprovidersinthehospital

5.Self-managementinthehospital6.Diabetesself-managementeducationinthehospital7.

Medicalnutritiontherapyinthehospital8.Bedsidebloodglucose


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monitoring9.DischargeplanningIX.STRATEGIESFORIMPROVINGDIABETESCARE,p.S46DDiabetesisachronicillnessthatrequirescontinuingmedicalcare

andongoingpatientself-managementeducationandsupporttopreventacutecomplicationsandto

reducetheriskoflong-termcomplications.Diabetescareiscomplexandrequiresthat

manyissues,beyondglycemiccontrol,beaddressed.Alargebody


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ofevidenceexiststhatsupportsarangeofinterventionstoimprovediabetesoutcomes.

Thesestandardsofcareareintended

to

provideclinicians,patients,research

ers,payors,andotherinterestedindivid

ualswiththecomponentsofdiabetes

care,generaltreatmentgoals,

andtoolsto

evaluatethequalityofcare.


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Whileindi

vidualpreferences,comorbidities,and

otherpatientfactorsmayrequiremodifi

cationofgoals,targetsthatare

desirable

formostpatientswithdiabetesarepro

vided.

Thesestandardsarenotintended

toprecludeclinicaljudgmentormore

ex

tensiveevaluationandmanagementofthe


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patientbyotherspecialistsasneeded.

Formoredetailedinformationabout

managementofdiabetes,refertorefer

ences13.

Therecommendationsincludedare

screening,diagnostic,and

therapeuticac

tionsthatareknownorbelievedtofavor

ablyaffecthealthoutcomesofpatients

with


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diabetes.Agradingsystem(Table1),

developedbytheAmericanDiabetesAs

sociation(ADA)andmodeledafterexist

ingmethods,wasutilizedtoclarifyand

codifytheevidencethat

formsthebasis

fortherecommendations.Thelevelofev

idencethatsupportseachrecommenda

care.diabetesjournals.orgDIABETES


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CARE,VOLUME34,SUPPLEMENT1,JANUARY2011S11


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StandardsofMedicalCare

Table1ADAevidencegradingsystemforclinicalpracticerecommendations

LevelofevidenceDescription

AClearevidencefromwell-conducted,generalizable,randomizedcontrolledtrialsthatareadequatelypowered,

including:Evidencefromawell-conductedmulticentertrialEvidencefromameta-analysis

thatincorporatedqualityratingsintheanalysisCompellingnonexperimentalevidence,


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i.e.,allornoneruledevelopedbyCenterforEvidenceBasedMedicineatOxfordSupportiveevidencefromwell-conductedrandomizedcontrolledtrialsthatareadequately

powered,including:Evidencefromawell-conductedtrialatoneormoreinstitutions

Evidencefromameta-analysisthatincorporatedqualityratingsintheanalysisB

Supportiveevidencefromwell-conductedcohortstudiesEvidencefroma


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well-conductedprospectivecohortstudyorregistryEvidencefromawell-conductedmeta-analysisofcohortstudiesSupportiveevidencefromawell-conductedcase-controlstudyCSupportive

evidencefrompoorlycontrolledoruncontrolledstudiesEvidencefromrandomizedclinicaltrials

withoneormoremajororthreeormoreminormethodologicalflawsthat

couldinvalidatetheresultsEvidencefromobservationalstudieswith


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highpotentialforbias(suchascaseserieswithcomparisontohistoricalcontrols)EvidencefromcaseseriesorcasereportsConflictingevidencewith

theweightofevidencesupportingtherecommendationEExpertconsensusorclinicalexperience

tionislistedaftereachrecommendationusingthelettersA,B,

C,orE.

Thesestandardsofcareare


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revisedannuallybytheADAsmultidisciplinaryProfessionalPracticeCommittee,incorporatingnewevidence.MembersoftheProfessionalPracticeCommitteeandtheirdisclosedconflictsofinterest

arelistedonpageS97.Subsequently,aswithallPositionStatements,thestandards

ofcarearereviewedandapprovedbytheExecutiveCommitteeofADAsBoard

ofDirectors.

I.CLASSIFICATIONANDDIAGNOSISOFDIABETES


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A.ClassificationofdiabetesTheclassificationofdiabetesincludesfourclinicalclasses:

.Type1diabetes(resultsfrom-celldestruction,usuallyleading

toabsoluteinsulindeficiency).Type2diabetes(resultsfromaprogressiveinsulin

secretorydefectonthebackgroundofinsulinresistance).Otherspecifictypesof

diabetesduetoothercauses,e.g.,geneticdefectsin-cell


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function,geneticdefectsininsulinaction,diseasesoftheexocrinepancreas(suchascysticfibrosis),anddrug-orchemical-induced(suchasinthetreatment

ofHIV/AIDSorafterorgantransplantation)

.Gestationaldiabetesmellitus(GDM)

(diabetesdiagnosedduringpregnancythatisnotclearlyovertdiabetes)Somepatientscannot

beclearlyclassifiedashavingtype1ortype2


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diabetes.Clinicalpresentationanddiseaseprogressionvaryconsiderablyinbothtypesofdiabetes.Occasionally,patientswhootherwisehavetype2diabetesmaypresentwith

ketoacidosis.Similarly,patientswithtype1diabetesmayhavealateonsetand

slow(butrelentless)progressionofdiseasedespitehavingfeaturesofautoimmunedisease.Such

difficultiesindiagnosismayoccurinchildren,adolescents,andadults.


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Thetruediagnosismaybecomemoreobviousovertime.

B.DiagnosisofdiabetesFordecades,thediagnosisofdiabeteswasbasedon

plasmaglucosecriteria,eitherthefastingplasmaglucose(FPG)orthe

2-hvalueinthe75-goralglucosetolerancetest(OGTT)(4).

In2009,anInternationalExpertCommitteethatincludedrepresentativesof


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theADA,theInternationalDiabetesFederation(IDF),andtheEuropeanAssociationfortheStudyofDiabetes(EASD)recommendedtheuseoftheA1Ctest

todiagnosediabetes,withathresholdof6.5%(5),andADAadoptedthis

criterionin2010(4).Thediagnostictestshouldbeperformedusingamethod

thatiscertifiedbytheNationalGlycohemoglobinStandardizationProgram(NGSP)


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andstandardizedortraceabletotheDiabetesControlandComplicationsTrial(DCCT)referenceassay.Point-of-careA1Cassaysarenotsufficientlyaccurateatthistime

tousefordiagnosticpurposes.

Epidemiologicdatasetsshowasimilarrelationship

betweenA1Candriskofretinopathyashasbeenshownforthecorresponding

FPGand2-hplasmaglucosethresholds.TheA1Chasseveral


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advantagestotheFPGandOGTT,includinggreaterconvenience,sincefastingisnotrequired;evidencetosuggestgreaterpre-analyticalstability;andlessday-to-day

perturbationsduringperiodsofstressandillness.Theseadvantagesmustbebalancedby

greatercost,thelimitedavailabilityofA1Ctestingincertainregionsofthe

developingworld,andtheincompletecorrelationbetweenA1Candaverage


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glucoseincertainindividuals.Inaddition,A1Clevelscanvarywithpatientsethnicity(6)aswellaswithcertainanemiasandhemoglobinopathies.Forpatients

withanabnormalhemoglobinbutnormalredcellturnover,suchassicklecell

trait,anA1Cassaywithoutinterferencefromabnormalhemoglobinsshouldbeused(an

updatedlistisavailableatwww.ngsp.org/interf.asp).Forconditionswith


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abnormalredcellturnover,suchaspregnancy,recentbloodlossortransfusion,orsomeanemias,thediagnosisofdiabetesmustemployglucosecriteriaexclusively.

Theestablishedglucosecriteriaforthediagnosisofdiabetes(FPGand

2-hPG)remainvalidaswell(Table2).Justasthereisless

than100%concordancebetweentheFPGand2-hPGtests,


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thereisnotperfectconcordancebetweenA1Candeitherglucose-basedtest.AnalysesofNationalHealthandNutritionExaminationSurvey(NHANES)dataindicatethat,assuming

universalscreeningoftheundiagnosed,theA1Ccutpointof6.5%identifiesone-third

fewercasesofundiagnoseddiabetesthanafastingglucosecutpointof126

mg/dl(7.0mmol/l)(7).

S12DIABETESCARE,VOLUME


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34,SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatement

Table2Criteriaforthediagnosisofdiabetes

A1C6.5%.Thetestshouldbeperformedinalaboratory

usingamethodthatisNGSPcertifiedandstandardizedtotheDCCTassay.*

or

FPG126mg/dl(7.0mmol/l).Fastingisdefinedasno

caloricintakeforatleast8h.*or


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2-hplasmaglucose200mg/dl(11.1mmol/l)duringanOGTT.ThetestshouldbeperformedasdescribedbytheWorldHealthOrganization,usinga

glucoseloadcontainingtheequivalentof75ganhydrousglucosedissolvedinwater.*

or

Inapatientwithclassicsymptomsofhyperglycemiaorhyperglycemic

crisis,arandomplasmaglucose200mg/dl(11.1mmol/l)


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*Intheabsenceofunequivocalhyperglycemia,resultshouldbeconfirmedbyrepeattesting.

However,inpractice,alargeportionofthe

diabeticpopulationremainsunawareoftheircondition.Thus,thelowersensitivityofA1C

atthedesignatedcutpointmaywellbeoffsetbythetestsgreater

practicality,andwiderapplicationofamoreconvenienttest(A1C)


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mayactuallyincreasethenumberofdiagnosesmade.

Aswithmostdiagnostictests,atestresultdiagnosticofdiabetesshouldberepeated

toruleoutlaboratoryerror,unlessthediagnosisisclearonclinicalgrounds,

suchasapatientwithahyperglycemiccrisisorclassicsymptomsofhyperglycemia

andarandomplasmaglucose200mg/dl.Itispreferable


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thatthesametestberepeatedforconfirmation,sincetherewillbeagreaterlikelihoodofconcurrenceinthiscase.Forexample,ifthe

A1Cis7.0%andarepeatresultis6.8%,thediagnosisofdiabetes

isconfirmed.However,iftwodifferenttests(suchasA1CandFPG)are

bothabovethediagnosticthresholds,thediagnosisofdiabetesis


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alsoconfirmed.

Ontheotherhand,iftwodifferenttestsareavailableinanindividualandtheresultsarediscordant,thetest

whoseresultisabovethediagnosticcutpointshouldberepeated,andthe

diagnosisismadeonthebasisoftheconfirmedtest.Thatis,if

apatientmeetsthediabetescriterionoftheA1C(two


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results6.5%)butnottheFPG(126mg/dlor7.0mmol/l),orviceversa,thatpersonshouldbeconsideredtohavediabetes.

Sincethereispreanalyticandanalytic

variabilityofallthetests,

itisalsopossiblethatwhenatestwhoseresultwasabovethe

diagnosticthresholdisrepeated,thesecondvaluewillbebelow


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thediagnosticcutpoint.ThisisleastlikelyforA1C,somewhatmorelikelyforFPG,andmostlikelyforthe2-hPG.Barringa

laboratoryerror,suchpatientsarelikelytohavetestresultsnearthemargins

ofthethresholdforadiagnosis.Thehealthcareprofessionalmightopttofollow

thepatientcloselyandrepeatthetestingin36


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months.

ThecurrentdiagnosticcriteriafordiabetesaresummarizedinTable2.

C.Categoriesofincreasedriskfordiabetes(prediabetes)

In1997and2003,TheExpertCommitteeonDiagnosisandClassificationofDiabetes

Mellitus(8,9)recognizedanintermediategroupofindividualswhoseglucoselevels,althoughnot

meetingcriteriafordiabetes,areneverthelesstoohightobe


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considerednormal.Thesepersonsweredefinedashavingimpairedfastingglucose(IFG)(FPGlevels100125mg/dl

[5.66.9mmol/l])orimpairedglucosetolerance

(IGT)(2-hPGvaluesintheOGTTof140199mg/dl[7.811.0

mmol/l]).ItshouldbenotedthattheWorldHealthOrganization(WHO)anda

numberofotherdiabetesorganizationsdefinethecutoffforIFG


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at110mg/dl(6.1mmol/l).IndividualswithIFGand/orIGThavebeenreferredtoashavingprediabetes,indicatingtherelativelyhighriskforthe

futuredevelopmentofdiabetes.IFGandIGTshouldnotbeviewedasclinical

entitiesintheirownrightbutratherriskfactorsfordiabetesaswell

ascardiovasculardisease(CVD).IFGandIGTareassociatedwith


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obesity(especiallyabdominalorvisceralobesity),dyslipidemiawithhightriglyceridesand/orlowHDLcholesterol,andhypertension.

Asisthecasewiththe

glucosemeasures,severalprospectivestudiesthatusedA1Ctopredicttheprogressionto

diabetesdemonstratedastrong,continuousassociationbetweenA1Candsubsequentdiabetes.Ina

systematicreviewof44,203individualsfrom16cohortstudieswith


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afollow-upintervalaveraging5.6years(range2.812years),thosewithanA1Cbetween5.5and6.0%hadasubstantiallyincreasedriskofdiabetes

with5-yearincidencesrangingfrom925%.AnA1Crangeof6.06.5%had

a5-yearriskofdevelopingdiabetesbetween2550%andrelativerisk20

timeshigher

Table3Categoriesofincreasedriskfor


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diabetes(prediabetes)*

FPG100125mg/dl(5.66.9mmol/l):IFGor2-hplasmaglucoseinthe75-gOGTT140199mg/dl(7.811.0mmol/l):IGT

orA1C5.76.4%

*Forallthreetests,riskiscontinuous,extending

belowthelowerlimitoftherangeandbecomingdisproportionatelygreaterathigher

endsoftherange.

comparedwithanA1C


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of5.0%(10).Inacommunity-basedstudyofblackandwhiteadultswithoutdiabetes,baselineA1Cwasastrongerpredictorofsubsequentdiabetesand

cardiovasculareventsthanfastingglucose(11).OtheranalysessuggestthatanA1Cof

5.7%isassociatedwithdiabetesrisksimilartothatofthehigh-riskparticipants

intheDiabetesPreventionProgram(DPP).

Hence,it


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isreasonabletoconsideranA1Crangeof5.76.4%asidentifyingindividualswithhighriskforfuturediabetes,astatethatmaybereferred

toasprediabetes(4).Asisthecaseforindividualsfoundtohave

IFGandIGT,individualswithanA1Cof5.76.4%shouldbeinformedof

theirincreasedriskfordiabetesaswellasCVDand


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counseledabouteffectivestrategiestolowertheirrisks(see

IV.PREVENTION/DELAYOFTYPE2DIABETES).Aswithglucosemeasurements,thecontinuumof

riskiscurvilinearasA1Crises,theriskofdiabetesrisesdisproportionately(10).Accordingly,

interventionsshouldbemostintensiveandfollow-upparticularlyvigilantforthosewithA1Cs

above6.0%,whoshouldbeconsideredtobeatvery


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highrisk.Table3summarizesthecategoriesofincreasedriskfordiabetes.

II.TESTINGFORDIABETESINASYMPTOMATICPATIENTSRecommendations

.Testingtodetecttype2diabetesandassessriskforfuturediabetes

inasymptomaticpeopleshouldbeconsideredinadultsofanyagewhoare

overweightorobese(BMI25kg/m2)andwhohaveone


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ormoreadditionalriskfactorsfordiabetes(Table4).Inthosewithouttheseriskfactors,testingshouldbeginatage45years.(B).

Iftestsarenormal,repeattestingcarriedoutatleastat3-yearintervals

isreasonable.(E)care.diabetesjournals.orgDIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011S13


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Table4Criteriafortestingfordiabetesinasymptomaticadultindividuals

1.Testingshouldbeconsidered

inalladultswhoareoverweight(BMI25kg/m2*)andhaveadditionalrisk

factors:physicalinactivityfirst-degreerelativewithdiabeteshigh-riskrace/ethnicity(e.g.,

AfricanAmerican,Latino,NativeAmerican,AsianAmerican,PacificIslander)


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womenwhodeliveredababyweighing9lborwerediagnosedwithGDMhypertension(140/90mmHgorontherapyforhypertension)HDL

cholesterollevel35mg/dl(0.90mmol/l)and/oratriglyceridelevel250mg/dl(2.82

mmol/l)womenwithpolycysticovariansyndrome(PCOS)A1C5.7%,IGT,or

IFGonprevioustestingotherclinicalconditionsassociatedwith


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insulinresistance(e.g.,severeobesity,acanthosisnigricans)

historyofCVD2.Intheabsenceoftheabovecriteria,testingfordiabetes

shouldbeginatage45years.3.Ifresultsarenormal,testingshould

berepeatedatleastat3-yearintervals,withconsiderationofmorefrequenttesting

dependingoninitialresultsandriskstatus.*At-riskBMImay


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belowerinsomeethnicgroups.

.Totestfordiabetesortoassessriskoffuturediabetes,A1C,FPG,or2-h

75-gOGTTisappropriate.(B).Inthoseidentifiedwithincreasedriskfor

futurediabetes,identifyand,ifappropriate,treatotherCVDriskfactors.(B)For

manyillnesses,thereisamajordistinctionbetweenscreeningand


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diagnostictesting.However,fordiabetes,thesametestswouldbeusedforscreeningasfordiagnosis.Diabetesmaybeidentifiedanywherealongaspectrum

ofclinicalscenariosrangingfromaseeminglylow-riskindividualwhohappensto

haveglucosetesting,toahigher-riskindividualwhomtheprovidertestsbecauseof

highsuspicionofdiabetes,tothesymptomaticpatient.Thediscussion


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hereinisprimarilyframedastestingfordiabetesinthosewithoutsymptoms.Testingfordiabeteswillalsodetectindividualsatincreasedfutureriskfor

diabetes,hereinreferredtoashavingprediabetes.

A.Testingfortype

2diabetesandriskoffuturediabetesinadultsType2diabetesis

frequentlynotdiagnoseduntilcomplicationsappear,andapproximatelyone-fourthof


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allpeoplewithdiabetesintheU.S.maybeundiagnosed.Theeffectivenessofearlyidentificationofprediabetesanddiabetesthroughmasstestingofasymptomatic

individualshasnotbeenprovendefinitively,andrigoroustrialstoprovidesuchproof

areunlikelytooccur.However,mathematicalmodelingstudiessuggestthatscreeningindependentof

riskfactorsbeginningatage30or45yearsis


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highlycost-effective($11,000perquality-adjustedlife-yeargained)(12).Prediabetesanddiabetesmeetestablishedcriteriaforconditionsinwhichearlydetectionisappropriate.Both

conditionsarecommonandincreasinginprevalenceandimposesignificantpublichealthburdens.

Thereisalongpresymptomaticphasebeforethediagnosisoftype2diabetes

isusuallymade.Relativelysimpletestsareavailabletodetect


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preclinicaldisease.Additionally,thedurationofglycemicburdenisastrongpredictorofadverseoutcomes,andeffectiveinterventionsexisttopreventprogressionofprediabetes

todiabetes(seeIV.PREVENTION/DELAYOFTYPE2DIABETES)andtoreducerisk

ofcomplicationsofdiabetes(seeVI.PREVENTIONANDMANAGEMENTOFDIABETESCOMPLICATIONS).

Recommendationsfortestingfordiabetesinasymptomatic,undiagnosedadults


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arelistedinTable4.TestingshouldbeconsideredinadultsofanyagewithBMI25kg/m2andoneormoreofthe

knownriskfactorsfordiabetes.Becauseageisamajorriskfactorfor

diabetes,testingofthosewithoutotherriskfactorsshouldbeginnolaterthan

age45years.

EitherA1C,FPG,orthe


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2-hOGTTisappropriatefortesting.The2-hOGTTidentifiespeoplewitheitherIFGorIGTandthusmorepeopleatincreasedriskfor

thedevelopmentofdiabetesandCVD.Itshouldbenotedthatthetwo

testsdonotnecessarilydetectthesameindividuals.Theefficacyofinterventionsfor

primarypreventionoftype2diabetes(1319)haveprimarilybeen


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demonstratedamongindividualswithIGT,notforindividualswithIFG(whodonotalsohaveIGT)orforindividualswithspecificA1Clevels.

Theappropriateintervalbetweentestsisnotknown(20).Therationalefor

the3-yearintervalisthatfalsenegativeswillberepeatedbeforesubstantialtime

elapses,andthereislittlelikelihoodthatanindividualwill


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developsignificant

complicationsofdiabeteswithin3yearsofanegativetestresult.Inthemodelingstudy,repeatscreeningevery3or

5yearswascost-effective(12).

Becauseoftheneedforfollow-up

anddiscussionofabnormalresults,testingshouldbecarriedoutwithinthehealth

caresetting.Communityscreeningoutsideahealthcaresettingis


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notrecommendedbecausepeoplewithpositivetestsmaynotseek,orhaveaccessto,appropriatefollow-uptestingandcare.Conversely,theremaybefailure

toensureappropriaterepeattestingforindividualswhotestnegative.Communityscreeningmay

alsobepoorlytargeted,i.e.,itmayfailtoreachthegroupsmost

atriskandinappropriatelytestthoseatlowrisk(the


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worriedwell)oreventhosealreadydiagnosed.

B.Testingfortype2diabetesinchildrenTheincidenceoftype2diabetesin

adolescentshasincreaseddramaticallyinthelastdecade,especiallyinminoritypopulations(21),

althoughthediseaseremainsrareinthegeneralpediatricpopulation(22).Consistentwith

recommendationsforadults,childrenandyouthatincreasedriskfor


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thepresenceorthedevelopmentoftype2diabetesshouldbetestedwithinthehealthcaresetting.TherecommendationsoftheADAConsensusStatement

onType2DiabetesinChildrenandYouth(23),withsomemodifications,are

summarizedinTable5.

C.Screeningfortype1diabetesGenerally,

peoplewithtype1diabetespresentwithacutesymptomsof


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diabetesandmarkedlyelevatedbloodglucoselevels,andmostcasesarediagnosedsoonaftertheonsetofhyperglycemia.However,evidencefromtype1prevention

studiessuggeststhatmeasurementofisletautoantibodiesidentifiesindividualswhoareatrisk

fordevelopingtype1diabetes.Suchtestingmaybeappropriateinhigh-risk

individuals,suchasthosewithpriortransienthyperglycemiaorthose


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whohaverelativeswithtype1diabetes,inthecontextofclinicalresearchstudies(see,forexample,http://www2.diabetestrialnet.org).Widespreadclinicaltestingofasymptomaticlow-risk

individualscannotcurrentlyberecommended,asitwouldidentifyveryfewindividualsin

thegeneralpopulationwhoareatrisk.Individualswhoscreenpositiveshouldbe

counseledabouttheirriskofdevelopingdiabetes.Clinicalstudiesare


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beingconductedto

S14DIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatement

Table5Testingfortype2diabetesinasymptomaticchildren

Criteria

Overweight(BMI85thpercentile

forageandsex,weightforheight85thpercentile,orweight120%of

idealforheight)Plusanytwoofthefollowingriskfactors:

Familyhistoryoftype2diabetesinfirst-or


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second-degreerelativeRace/ethnicity(NativeAmerican,AfricanAmerican,Latino,AsianAmerican,PacificIslander)Signsofinsulinresistanceorconditionsassociatedwithinsulinresistance

(acanthosisnigricans,hypertension,dyslipidemia,PCOS,orsmall-forgestational-agebirthweight)Maternalhistory

ofdiabetesorGDMduringthechildsgestationAgeofinitiation:age10

yearsoratonsetofpuberty,ifpubertyoccursat


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ayoungerage

Frequency:every3years

testvariousmethodsofpreventingtype1diabetes,orreversingearlytype1

diabetes,inthosewithevidenceofautoimmunity.

III.DETECTIONANDDIAGNOSIS

OFGESTATIONALDIABETESMELLITUSRecommendations

.Screenforundiagnosedtype2

diabetesatthefirstprenatalvisitinthosewithrisk


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factors,usingstandarddiagnosticcriteria.(B).Inpregnantwomennotknowntohavediabetes,screenforGDMat2428weeksofgestation,

usinga75-g2-hOGTTandthediagnosticcutpointsinTable6.

(B).ScreenwomenwithGDMforpersistentdiabetes612weekspostpartum.(E)

.WomenwithahistoryofGDMshouldhavelifelong


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screeningforthedevelopmentofdiabetesorprediabetesatleastevery3years.(E)Formanyyears,GDMwasdefinedasanydegreeof

glucoseintolerancewithonsetorfirstrecognitionduringpregnancy(8),whetherornot

theconditionpersistedafterpregnancy,andnotexcludingthepossibilitythatunrecognizedglucose

intolerancemayhaveantedatedorbegunconcomitantlywiththepregnancy.


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Thisdefinitionfacilitatedauniformstrategy

fordetectionandclassificationofGDM,butitslimitationswererecognizedformanyyears.Asthe

ongoingepidemicofobesityanddiabeteshasledtomoretype2diabetes

inwomenofchildbearingage,thenumberofpregnantwomenwithundiagnosedtype

2diabeteshasincreased(24).Becauseofthis,itis


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reasonabletoscreenwomenwithriskfactorsfortype2diabetes(Table4)fordiabetesattheirinitialprenatalvisit,usingstandarddiagnosticcriteria

(Table2).Womenwithdiabetesfoundatthisvisitshouldreceiveadiagnosis

ofovert,notgestational,diabetes.

GDMcarriesrisksforthemother

andneonate.TheHyperglycemiaandAdversePregnancyOutcomes(HAPO)study


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(25),alarge-scale(25,000pregnantwomen)multinationalepidemiologicstudy,demonstratedthatriskofadversematernal,fetal,andneonataloutcomescontinuouslyincreasedasafunction

ofmaternalglycemiaat2428weeks,evenwithinrangespreviouslyconsiderednormalfor

pregnancy.Formostcomplications,therewasnothresholdforrisk.Theseresultshave

ledtocarefulreconsiderationofthediagnosticcriteriaforGDM.


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Afterdeliberationsin20082009,theInternationalAssociationofDiabetesandPregnancyStudyGroups(IADPSG),aninternationalconsensusgroupwithrepresentativesfrommultipleobstetricaland

diabetesorganizations,includingADA,developedrevisedrecommendationsfordiagnosingGDM.Thegrouprecommended

thatallwomennotknowntohavediabetesundergoa75-gOGTTat

2428weeksofgestation.Additionally,thegroupdevelopeddiagnosticcut


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pointsforthefasting,1-h,and2-hplasmaglucosemeasurementsthatconveyedanoddsratioforadverseoutcomesofatleast1.75comparedwith

themeanglucoselevelsintheHAPOstudy.Currentscreeninganddiagnosticstrategies,

basedontheIADPSGstatement(26),areoutlinedinTable6.

ThesenewcriteriawillsignificantlyincreasetheprevalenceofGDM,


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primarilybecauseonlyoneabnormalvalue,nottwo,issufficienttomakethediagnosis.TheADArecognizestheanticipatedsignificantincreaseintheincidence

ofGDMtobediagnosedbythesecriteriaandissensitivetoconcerns

aboutthemedicalizationofpregnanciespreviouslycategorizedasnormal.Thesediagnosticcriteriachanges

arebeingmadeinthecontextofworrisomeworldwideincreases


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inobesityanddiabetesrates,withtheintentof

Table6ScreeningforanddiagnosisofGDM

Performa75-gOGTT,

withplasmaglucosemeasurementfastingandat1and2h,at2428

weeksofgestationinwomennotpreviouslydiagnosedwithovertdiabetes.

TheOGTTshouldbeperformedinthemorningafteran


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overnightfastofatleast8h.

ThediagnosisofGDMismadewhenanyofthefollowingplasmaglucosevaluesare

exceeded:

Fasting92mg/dl(5.1mmol/l)1h180mg/dl

(10.0mmol/l)2h153mg/dl(8.5mmol/l)optimizinggestationaloutcomesforwomen

andtheirbabies.

Admittedly,therearefewdata


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fromrandomizedclinicaltrialsregardingtherapeuticinterventionsinwomenwhowillnowbediagnosedwithGDMbasedononlyonebloodglucosevalueabove

thespecifiedcutpoints(incontrasttotheoldercriteriathatstipulatedat

leasttwoabnormalvalues.)Expectedbenefitstotheirpregnanciesandoffspringisinferred

frominterventiontrialsthatfocusedonwomenwithmoremild


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hyperglycemiathanidentifiedusingolderGDMdiagnosticcriteriaandthatfoundmodestbenefits(27,28).Thefrequencyoftheirfollow-upandbloodglucosemonitoringis

notyetclear,butlikelytobelessintensivethanwomendiagnosedby

theoldercriteria.Additionalwell-designedclinicalstudiesareneededtodeterminetheoptimal

intensityofmonitoringandtreatmentofwomenwithGDMdiagnosed


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bythenewcriteria(thatwouldnothavemetthepriordefinitionofGDM).Itisimportanttonotethat8090%ofwomenin

bothofthemildGDMstudies(whoseglucosevaluesoverlappedwiththethresholds

recommendedherein)couldbemanagedwithlifestyletherapyalone.

Becausesome

casesofGDMmayrepresentpreexistingundiagnosedtype2diabetes,


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womenwithahistoryofGDMshouldbescreenedfordiabetes612weekspostpartum,usingnonpregnantOGTTcriteria.Womenwithahistoryof

GDMhaveagreatlyincreasedsubsequentriskfordiabetes(29)andshouldbe

followedupwithsubsequentscreeningforthedevelopmentofdiabetesorprediabetes,as

outlinedinII.TESTINGFORDIABETESINASYMPTOMATICPATIENTS.


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care.diabetesjournals.orgDIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011S15


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StandardsofMedicalCareTable7Therapiesproveneffectiveindiabetespreventiontrials

Incidencein3-YearMeancontrolRelativerisknumberage

DurationInterventionsubjectsreduction(%)neededtoStudy(ref.)nPopulation(years)(years)

(dailydose)(%/year)(95%CI)treat.

LifestyleFinnishDPS(14)522

IGT,BMI25kg/m2553.2I-D&E658(3070)


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8.5DPP(13)2,161*IGT,BMI24kg/m2,513I-D&E10.458(4866)6.9

FPG5.3mmol/lDaQing(15)259*

IGT(randomizedgroups)456G-D&E14.538(1456)7.9ToranomonStudy458

IGT(men),BMI.24554I-D&E2.467(P.0.043)20.6

(35)kg/m2IndianDPP(19)269*IGT46


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2.5I-D&E2329(2137)6.4MedicationsDPP(13)2,155*IGT,BMI24kg/m2,512.8Metformin(1,70010.431(1743)13.9FPG5.3

mmol/lmg)IndianDPP(19)269*IGT462.5Metformin(500mg)23

26(1935)6.9STOP-NIDDM(17)1,419IGT,FPG5.6mmol/l543.2Acarbose

(300mg)12.425(1037)9.6XENDOS(36)3,277BMI


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30kg/m2434Orlistat(360mg)2.437(1454)45.5DREAM(18)5,269IGTorIFG553.0Rosiglitazone(8mg)9.160

(5465)6.9VoglibosePh-31,780IGT563.0(1-yearVogliobose(0.2mg)12.0

40(1857)21(1-year

(37)Rx)Rx)Modifiedandreprintedwith

permission(38).Percentagepoints:Numberneededtotreattoprevent


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1caseofdiabetes,standardizedfora3-yearperiodtoimprovecomparisonsacrossstudies.*Numberofparticipantsintheindicatedcomparisons,notnecessarilyin

entirestudy.Calculatedfrominformationinthearticle.DPP,DiabetesPreventionProgram;DPS,

DiabetesPreventionStudy;DREAM,DiabetesReductionAssessmentwithRamiprilandRosiglitazoneMedication;STOP-NIDDM,

StudytoPreventNon-InsulinDependentDiabetes;XENDOS,Xenicalinthe


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preventionofDiabetesinObeseSubjects.I,individual;G,group;D&E,dietandexercise.

IV.PREVENTION/DELAYOFTYPE2DIABETESRecommendations

.PatientswithIGT(A),IFG(E),oranA1Cof5.7

6.4%(E)shouldbereferredtoaneffectiveongoingsupportprogramtargetingweight

lossof7%ofbodyweightandincreasingphysicalactivity


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toatleast150min/weekofmoderateactivitysuchaswalking..Follow-upcounselingappearstobeimportantforsuccess.(B).Basedon

potentialcostsavingsofdiabetesprevention,suchprogramsshouldbecoveredbythird-party

payors.(E).Metformintherapyforpreventionoftype2diabetesmaybe

consideredinthoseatthehighestriskfordevelopingdiabetes,


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suchasthosewithmultipleriskfactors,especiallyiftheydemonstrateprogressionofhyperglycemia(e.g.,A1C6%)despitelifestyleinterventions.(B).Monitoringfor

thedevelopmentofdiabetesinthosewithprediabetesshouldbeperformedeveryyear.

(E)Randomizedcontrolledtrialshaveshownthatindividualsathighriskfordeveloping

diabetes(thosewithIFG,IGT,orboth)canbegiven


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interventionsthatsignificantlydecreasetherateofonsetofdi

abetes(1319).Theseinterventionsincludeintensivelifestylemodificationprogramsthathavebeen

showntobeveryeffective(58%reductionafter3years)anduseof

thepharmacologicagentsmetformin,-glucosidaseinhibitors,orlistat,andthiazolidinediones(TZDs),eachofwhich

hasbeenshowntodecreaseincidentdiabetestovariousdegrees.


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AsummaryofmajordiabetespreventiontrialsisshowninTable7.

Follow-upofallthreelargestudiesoflifestyleinterventionhas

shownsustainedreductionintherateofconversiontotype2diabetes,with

43%reductionat20yearsintheDaQingstudy(30),43%reduction

at7yearsintheFinnishDiabetesPreventionStudy(DPS)


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(31)and34%reductionat10yearsintheU.S.DiabetesPreventionProgramOutcomesStudy(DPPOS)(32).Acost-effectivenessanalysissuggestedthatlifestyleinterventions

asdeliveredintheDPParecost-effective(33).GroupdeliveryoftheDPP

interventionincommunitysettingshasthepotentialtobesignificantlylessexpensivewhile

stillachievingsimilarweightloss(34).

Basedon


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theresultsofclinicaltrialsandtheknownrisksofprogressionofprediabetestodiabetes,personswithanA1Cof5.76.4%,IGT,orIFG

shouldbecounseledonlifestylechangeswithgoalssimilartothoseofthe

DPP(7%weight

lossandmoderatephysicalactivityofatleast

150min/week).Regardingthemoredifficultissueofdrugtherapy


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fordiabetesprevention,aconsensuspanelfeltthatmetforminshouldbetheonlydrugconsidered(39).Forotherdrugs,theissuesofcost,side

effects,andlackofpersistenceofeffectinsomestudiesledthepanel

tonotrecommendtheirusefordiabetesprevention.Metformin,whichwassignificantlyless

effectivethanlifestyleintheDPPandDPPOS,reasonablymay


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berecommendedforvery-high-riskindividuals(thosewithriskfactorsfordiabetesand/orthosewithmoresevereorprogressivehyperglycemia).Ofnote,intheDPP

metforminwasmosteffectivecomparedtolifestyleinthosewithBMIofat

least35kg/m2andwasnotsignificantlybetterthanplacebointhoseover

age60years.

V.DIABETESCAREA.Initial


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evaluationAcompletemedicalevaluationshouldbeperformedtoclassifythediabetes,detectthepresenceofdiabetescomplications,reviewprevioustreatmentandglycemiccontrol

inpatientswithestablisheddiabetes,assistinformulatingamanagementplan,andprovide

abasisforcontinuingcare.Laboratorytestsappropriatetotheevaluationofeach

patientsmedicalcon

S16DIABETESCARE,VOLUME34,


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SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatement

ditionshouldbeperformed.Afocusonthecomponentsofcomprehensivecare(Table8)willassistthehealthcare

teamtoensureoptimalmanagementofthepatientwithdiabetes.

B.

ManagementPeoplewithdiabetesshouldreceivemedicalcarefromaphysician-coordinatedteam.Such

teamsmayinclude,butarenotlimitedto,physicians,nurse


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practitioners,physiciansassistants,nurses,dietitians,pharmacists,andmentalhealthprofessionalswithexpertiseandaspecialinterestindiabetes.Itisessentialinthiscollaborative

andintegratedteamapproachthatindividualswithdiabetesassumeanactiverolein

theircare.

Themanagementplanshouldbeformulatedasacollaborative

therapeuticallianceamongthepatientandfamily,thephysician,and


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othermembersofthehealthcareteam.Avarietyofstrategiesandtechniquesshouldbeusedtoprovideadequateeducationanddevelopmentofproblem-solving

skillsinthevariousaspectsofdiabetesmanagement.Implementationofthemanagementplan

requiresthateachaspectisunderstoodandagreedtobythepatientand

thecareprovidersandthatthegoalsandtreatmentplan


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arereasonable.Anyplanshouldrecognizediabetesself-managementeducation(DSME)andongoingdiabetessupportasanintegralcomponentofcare.Indevelopingthe

plan,considerationshouldbegiventothepatientsage,schoolorworkschedule

andconditions,physicalactivity,eatingpatterns,socialsituationandculturalfactors,andpresence

ofcomplicationsofdiabetesorothermedicalconditions.


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C.Glycemiccontrol1.AssessmentofglycemiccontrolTwoprimarytechniquesareavailableforhealthprovidersandpatientstoassesstheeffectivenessofthe

managementplanonglycemiccontrol:patientself-monitoringofbloodglucose(SMBG)orinterstitial

glucose,andA1C.

a.GlucosemonitoringRecommendations

.SMBG

shouldbecarriedoutthreeormoretimesdailyfor


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patientsusingmultipleinsulininjectionsorinsulinpumptherapy.(A)Table8Componentsofthecomprehensivediabetesevaluation

Medicalhistory

Ageandcharacteristicsofonsetofdiabetes(e.g.,DKA,asymptomaticlaboratoryfinding)

Eatingpatterns,physicalactivityhabits,nutritionalstatus,andweighthistory;growthanddevelopment

inchildrenandadolescentsDiabeteseducationhistoryReview


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ofprevioustreatmentregimensandresponsetotherapy(A1Crecords)Currenttreatmentofdiabetes,includingmedications,mealplan,physicalactivitypatterns,andresults

ofglucosemonitoringandpatientsuseofdataDKAfrequency,severity,and

causeHypoglycemicepisodesHypoglycemiaawarenessAnyseverehypoglycemia:frequencyand

causeHistoryofdiabetes-relatedcomplicationsMicrovascular:retinopathy,nephropathy,


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neuropathy(sensory,includinghistoryoffootlesions;autonomic,includingsexualdysfunctionandgastroparesis)Macrovascular:CHD,cerebrovasculardisease,PADOther:psychosocialproblems*,dental

disease*PhysicalexaminationHeight,weight,BMIBloodpressuredetermination,includingorthostatic

measurementswhenindicatedFundoscopicexamination*ThyroidpalpationSkinexamination(for

acanthosisnigricansandinsulininjectionsites)Comprehensivefootexamination:


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InspectionPalpationofdorsalispedisandposteriortibialpulsesPresence/absenceofpatellarandAchillesreflexesDeterminationofproprioception,vibration,and

monofilamentsensationLaboratoryevaluationA1C,ifresultsnotavailablewithinpast23

monthsIfnotperformed/availablewithinpastyear:Fastinglipidprofile,including

total,LDLandHDLcholesterolandtriglyceridesLiverfunction


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testsTestforurinealbuminexcretionwithspoturinealbumin-to-creatinineratioSerumcreatinineandcalculatedGFRThyroid-stimulatinghormoneintype1

diabetes,dyslipidemia,orwomenoverage50yearsReferrals

Annual

dilatedeyeexamFamilyplanningforwomenofreproductiveageRegistered

dietitianforMNTDSMEDentalexaminationMental


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healthprofessional,ifneeded*Seeappropriatereferralsforthesecategories.

.Forpatientsusingless-frequentinsulininjections,noninsulintherapies,ormedicalnutrition

therapy(MNT)alone,SMBGmaybeusefulasaguidetothesuccess

oftherapy.(E).Toachievepostprandialglucosetargets,postprandialSMBGmaybe

appropriate.(E).WhenprescribingSMBG,ensurethatpatientsreceive


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initialinstructionin,androutinefollow-upevaluationof,SMBGtechniqueandtheirabilitytousedatatoadjusttherapy.(E).Continuousglucosemonitoring

(CGM)inconjunctionwithintensiveinsulinregimenscanbeausefultoolto

lowerA1Cinselectedadults(age25years)withtype1diabetes.(A)

.AlthoughtheevidenceforA1Cloweringisless


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stronginchildren,teens,andyoungeradults,CGMmaybehelpfulinthesegroups.Successcorrelateswithadherencetoongoinguseofthedevice.

(C).CGMmaybeasupplementaltooltoSMBGinthosewith

hypoglycemiaunawarenessand/orfrequenthypoglycemicepisodes.(E)care.diabetesjournals.orgDIABETESCARE,VOLUME34,SUPPLEMENT

1,JANUARY2011S17


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Majorclinicaltrialsofinsulin-treatedpatientsthatdemonstratedthebenefitsofintensiveglycemiccontrolondiabetescomplications

haveincludedSMBGaspartofmultifactorialinterventions,suggestingthatSMBGisa

componentofeffectivetherapy.SMBGallowspatientstoevaluatetheirindividualresponseto

therapyandassesswhetherglycemictargetsarebeingachieved.Results


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ofSMBGcanbeusefulinpreventinghypoglycemiaandadjustingmedications(particularlyprandialinsulindoses),MNT,andphysicalactivity.

Thefrequencyand

timingofSMBGshouldbedictatedbytheparticularneedsandgoalsof

thepatient.SMBGisespeciallyimportantforpatientstreatedwithinsulintomonitor

forandpreventasymptomatichypoglycemiaandhyperglycemia.Formostpatients


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withtype1diabetesandpregnantwomentakinginsulin,SMBGisrecommendedthreeormoretimesdaily.Forthesepopulations,significantlymorefrequenttesting

mayberequiredtoreachA1Ctargetssafelywithouthypoglycemia.Theoptimalfrequency

andtimingofSMBGforpatientswithtype2diabetesonnoninsulintherapy

isunclear.Ameta-analysisofSMBGinnoninsulin-treatedpatients


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withtype2diabetesconcludedthatsomeregimenofSMBGwasassociatedwithareductioninA1Cof0.4%.However,manyofthestudies

inthisanalysisalsoincludedpatienteducationwithdietandexercisecounselingand,

insomecases,pharmacologicintervention,makingitdifficulttoassessthecontributionof

SMBGalonetoimprovedcontrol(40).Severalrecenttrialshave


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calledintoquestiontheclinicalutilityandcost-effectivenessofroutineSMBGinnoninsulin-treatedpatients(4143).

BecausetheaccuracyofSMBGisinstrument

anduserdependent(44),itisimportanttoevaluateeachpatientsmonitoringtechnique,

bothinitiallyandatregularintervalsthereafter.Inaddition,optimaluseofSMBG

requiresproperinterpretationofthedata.Patientsshouldbetaught


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howtousethedatatoadjustfoodintake,exercise,orpharmacologicaltherapytoachievespecificglycemicgoals,andtheseskillsshouldbereevaluated

periodically.

CGMthroughthemeasurementofinterstitialglucose(whichcorrelateswell

withplasmaglucose)isavailable.ThesesensorsrequirecalibrationwithSMBG,andthe

latterarestillrecommendedformakingacutetreatmentdecisions.CGM


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devicesalsohavealarmsforhypo-and

hyperglycemicexcursions.Smallstudiesinselectedpatientswithtype1diabeteshavesuggestedthatCGMuse

reducesthetimespentinhypo-andhyperglycemicrangesandmaymodestlyimproveglycemic

control.Alarger26-weekrandomizedtrialof322type1patientsshowedthat

adultsage25yearsandolderusingintensiveinsulintherapy


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andCGMexperienceda0.5%reductioninA1C(from

7.6%to7.1%)comparedtousualintensiveinsulintherapywithSMBG(45).Sensor

useinchildren,teens,andadultsuptoage24yearsdidnot

resultinsignificantA1Clowering,andtherewasnosignificantdifferenceinhypoglycemia

inanygroup.Importantly,thegreatestpredictorofA1C-loweringin


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thisstudyforallage-groupswasfrequencyofsensoruse,whichwaslowerinyoungerage-groups.Inasmallerrandomizedcontrolledtrialof

129adultsandchildrenwithbaselineA1C7.0%,outcomescombiningA1Candhypoglycemia

favoredthegrouputilizingCGM,suggestingthatCGMisalsobeneficialforindividuals

withtype1diabeteswhohavealreadyachievedexcellentcontrol


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withA1C7.0(46).AlthoughCGMisanevolvingtechnology,emergingdatasuggestthat,inappropriatelyselectedpatientswhoaremotivatedtowearit

mostofthetime,itmayofferbenefit.CGMmaybeparticularlyuseful

inthosewithhypoglycemiaunawarenessand/orfrequentepisodesofhypoglycemia,andstudiesin

thisareaareongoing.b.A1CRecommendations

.


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PerformtheA1Ctestatleasttwotimesayearinpatientswhoaremeetingtreatmentgoals(andwhohavestableglycemiccontrol).(E)

.PerformtheA1Ctestquarterlyinpatientswhosetherapyhaschangedor

whoarenotmeetingglycemicgoals.(E).Useofpoint-of-caretestingfor

A1Callowsfortimelydecisionsontherapychanges,whenneeded.


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(E)BecauseA1Cisthoughttoreflectaverageglycemiaoverseveralmonths(44),andhasstrongpredictivevaluefordiabetescomplications(47,48),A1Ctesting

shouldbeperformedroutinelyinallpatientswithdiabetes,atinitialassessmentand

thenaspartofcontinuingcare.Measurementapproximatelyevery3monthsdetermineswhether

apatientsglycemictargetshavebeenreachedandmaintained.For


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anyindividualpatient,thefre-

Table9CorrelationofA1Cwithaverageglucose

MeanplasmaglucoseA1C(%)mg/dlmmol/l6126

7.071548.6818310.2921211.81024013.4

1126914.91229816.5

Theseestimatesarebasedon

ADAGdataof2,700glucosemeasurementsover3monthsper


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A1Cmeasurementin507adultswithtype1,type2,andnodiabetes.ThecorrelationbetweenA1Candaverageglucosewas0.92(51).A

calculatorforconvertingA1Cresultsintoestimatedaverageglucose(eAG),ineithermg/dl

ormmol/l,isavailableathttp://professional.diabetes.org/eAG.

quencyofA1Ctesting

shouldbedependentontheclinicalsituation,thetreatmentregimen


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used,andthejudgmentoftheclinician.Somepatientswithstableglycemiawellwithintargetmaydowellwithtestingonlytwiceperyear,

whileunstableorhighlyintensivelymanagedpatients(e.g.,pregnanttype1women)may

betestedmorefrequentlythanevery3months.TheavailabilityoftheA1C

resultatthetimethatthepatientisseen(point-of-care


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testing)hasbeenreportedtoresultinincreasedintensificationoftherapyandimprovementinglycemiccontrol(49,50).

TheA1Ctestissubject

tocertainlimitations.Conditionsthataffecterythrocyteturnover(hemolysis,bloodloss)andhemoglobin

variantsmustbeconsidered,particularlywhentheA1Cresultdoesnotcorrelatewith

thepatientsclinicalsituation(44).Inaddition,A1Cdoesnot


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provideameasureofglycemicvariabilityorhypoglycemia.Forpatientspronetoglycemicvariability(especiallytype1patients,ortype2patientswithsevere

insulindeficiency),glycemiccontrolisbestjudgedbythecombinationofresultsof

SMBGtestingandtheA1C.TheA1Cmayalsoserveasacheck

ontheaccuracyofthepatientsmeter(orthepatients


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reportedSMBGresults)andtheadequacyoftheSMBGtestingschedule.

Table9containsthecorrelationbetweenA1Clevelsandmeanplasma

glucoselevelsbasedondatafromtheinternationalA1C-DerivedAverageGlucose(ADAG)trial

utilizingfrequentSMBGandCGMin507adults(83%Caucasian)withtype1,

type2,andnodiabe

S18DIABETESCARE,


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VOLUME34,SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatement

tes(51).TheAmericanDiabetesAssociationandAmericanAssociationofClinicalChemistshavedeterminedthatthecorrelation(r.

0.92)isstrongenoughtojustifyreportingbothanA1Cresultandan

estimatedaverageglucose(eAG)resultwhenaclinicianorderstheA1Ctest.The

tableinpreviousversionsoftheStandardsofMedicalCare


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inDiabetesdescribingthecorrelationbetweenA1Candmeanglucosewasderivedfromrelativelysparsedata(one7-pointprofileover1dayperA1C

reading)intheprimarilyCaucasiantype1diabeticparticipantsintheDCCT(52).

Cliniciansshouldnotethatthenumbersinthetablearenowdifferent,as

theyarebasedon

2,800readingsperA1C


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intheADAGtrial.IntheADAGtrial,therewerenosignificantdifferencesamongracialandethnicgroupsintheregressionlinesbetweenA1C

andmeanglucose,althoughtherewasatrendtowardadifferencebetweenAfrican/African

AmericanparticipantsandCaucasianonesthatmighthavebeensignificanthadmoreAfrican/African

Americanparticipantsbeenstudied.ArecentstudycomparingA1Cwith


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CGMdatain48type1diabeticchildrenfoundahighlystatisticallysignificantcorrelationbetweenA1Candmeanbloodglucose,althoughthecorrelation(r

.0.7)wassignificantlylowerthanintheADAGtrial(53).Whetherthere

aresignificantdifferencesinhowA1Crelatestoaverageglucoseinchildrenor

inAfricanAmericanpatientsisanareaforfurtherstudy.


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Forthetimebeing,thequestionhasnotledtodifferentrecommendationsabouttestingA1Cortodifferentinterpretationsoftheclinicalmeaningof

givenlevelsofA1Cinthosepopulations.

Forpatientsinwhom

A1C/eAGandmeasuredbloodglucoseappeardiscrepant,cliniciansshouldconsiderthepossibilitiesof

hemoglobinopathyoralteredredcellturnover,andtheoptionsof


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morefrequentand/ordifferenttimingofSMBGoruseofCGM.Othermeasuresofchronicglycemiasuchasfructosamineareavailable,buttheirlinkage

toaverageglucoseandtheirprognosticsignificancearenotasclearasis

thecaseforA1C.

2.GlycemicgoalsinadultsRecommendations

.LoweringA1Ctobeloworaround7%has


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beenshowntoreducemicrovascularandneuropathiccomplicationsofdiabetesand,ifimplementedsoonafterthediagnosisofdiabetes,isassociatedwithlong-termreduction

inmacrovasculardisease.Therefore,areasonableA1Cgoalformanynonpregnantadultsis

7%.(B)

.Becauseadditionalanalysesfromseveralrandomizedtrialssuggest

asmallbutincrementalbenefitinmicrovascularoutcomeswithA1C


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valuesclosertonormal,providersmightreasonablysuggestmorestringentA1Cgoalsforselectedindividualpatients,ifthiscanbeachievedwithoutsignificanthypoglycemia

orotheradverseeffectsoftreatment.Suchpatientsmightincludethosewithshort

durationofdiabetes,longlifeexpectancy,andnosignificantCVD.(B).Conversely,

lessstringentA1Cgoalsmaybeappropriateforpatientswith


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ahistoryofseverehypoglycemia,limitedlifeexpectancy,advancedmicrovascularormacrovascularcomplications,extensivecomorbidconditions,andthosewithlongstandingdiabetesinwhomthe

generalgoalisdifficulttoattaindespiteDSME,appropriateglucosemonitoring,andeffective

dosesofmultipleglucose-loweringagentsincludinginsulin.(C)Glycemiccontrolisfundamentalto

themanagementofdiabetes.TheDCCT(47)(inpatientswith


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type1diabetes),theKumamotostudy(54),andtheUKProspectiveDiabetesStudy(UKPDS)(55,56)(bothinpatientswithtype2diabetes)wereprospective,

randomized,controlledtrialsofintensiveversusstandardglycemiccontrolinpatientswithrelatively

recentlydiagnoseddiabetes.Thesetrialsshoweddefinitivelythatimprovedglycemiccontrolisassociated

withsignificantlydecreasedratesofmicrovascular(retinopathyandnephropathy)and


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neuropathiccomplications.FollowupoftheDCCTcohortsintheEpidemiologyofDiabetesInterventionsandComplications(EDIC)study(57,58)andoftheUKPDScohort

(59)hasshownpersistenceofthesemicrovascularbenefitsinpreviouslyintensivelytreatedsubjects,

eventhoughtheirglycemiccontrolhasbeenequivalenttothatofpreviousstandard

armsubjectsduringfollow-up.

Subsequenttrialsinpatients


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withmorelong-standingtype2diabetes,designedprimarilytolookattheroleofintensiveglycemiccontroloncardiovascularoutcomesalsoconfirmedabenefit,

althoughmoremodest,ononsetorprogressionofmicrovascularcomplications.

The

VeteransAffairsDiabetesTrial(VADT)showedsignificantreductionsinalbuminuriawithintensive(achieved

medianA1C6.9%)comparedtostandardglycemiccontrol,butno


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differenceinretinopathyandneuropathy(60,61).TheActioninDiabetesandVascularDisease:PreteraxandDiamicronModifiedReleaseControlledEvaluation(ADVANCE)studyofintensive

versusstandardglycemiccontrolintype2diabetesfoundastatisticallysignificantreduction

inalbuminuriawithanA1Ctargetof6.5%(achievedmedianA1C6.3%)compared

tostandardtherapyachievingamedianA1Cof7.0%(62).


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RecentanalysesfromtheActiontoControlCardiovascularRiskinDiabetes(ACCORD)trialhaveshownlowerratesofmeasuresofmicrovascularcomplicationsinthe

intensiveglycemiccontrolarmcomparedwiththestandardarm(63,64).

Epidemiological

analysesoftheDCCTandUKPDS(47,48)demonstrateacurvilinearrelationshipbetweenA1C

andmicrovascularcomplications.Suchanalysessuggestthat,onapopulation


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level,thegreatestnumberofcomplicationswillbeavertedbytakingpatientsfromverypoorcontroltofairorgoodcontrol.Theseanalysesalso

suggestthatfurtherloweringofA1Cfrom7to6%isassociatedwith

furtherreductionintheriskofmicrovascularcomplications,albeittheabsoluteriskreductions

becomemuchsmaller.Giventhesubstantiallyincreasedriskofhypoglycemia


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(particularlyinthosewithtype1diabetes,butalsointherecenttype2trials),theconcerningmortalityfindingsintheACCORDtrial(65),

andtherelativelymuchgreatereffortrequiredtoachievenear-normoglycemia,therisksof

lowertargetsmayoutweighthepotentialbenefitsonmicrovascularcomplicationsonapopulation

level.However,selectedindividualpatients,especiallythosewithlittlecomorbidity


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andlonglifeexpectancy(whomayreapthebenefitsoffurtherloweringofglycemiabelow7%)may,atpatientandproviderjudgment,adoptglycemic

targetsasclosetonormalaspossibleaslongassignificanthypoglycemiadoes

notbecomeabarrier.

Whereasmanyepidemiologicstudiesandmeta-analyses(66,67)

haveclearlyshownadirectrelationshipbetweenA1CandCVD,


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thepotentialofintensiveglycemiccontroltoreduceCVDhasbeenlessclearlydefined.IntheDCCT,therewasatrendtowardlowerrisk

ofCVDeventswithintensivecontrol.However,9-yearpost-DCCTfollow-upofthecohort

has

care.diabetesjournals.orgDIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011S19


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shownthatparticipantspreviouslyrandomizedtotheintensivearmhada42%reduction(P.0.02)in

CVDoutcomesanda57%reduction(P.0.02)intheriskof

nonfatalmyocardialinfarction(MI),stroke,orCVDdeathcomparedwiththosepreviouslyin

thestandardarm(68).Thebenefitofintensiveglycemiccontrol


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inthistype1cohorthasrecentlybeenshowntopersistforseveraldecades(69).

TheUKPDStrialoftype2diabetes

observeda16%reductionincardiovascularcomplications(combinedfatalornonfatalMIand

suddendeath)intheintensiveglycemiccontrolarm,althoughthisdifferencewasnot

statisticallysignificant(P.0.052),andtherewasnosuggestion


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ofbenefitonotherCVDoutcomessuchasstroke.However,10yearsoffollow-upoftheUKPDScohortdemonstrated,forparticipantsoriginallyrandomized

tointensiveglycemiccontrolcomparedwiththoserandomizedtoconventionalglycemiccontrol,long-term

reductionsinMI(15%withsulfonylureaorinsulinasinitialpharmacotherapy,33%with

metforminasinitialpharmacotherapy,bothstatisticallysignificant)andinall-cause


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mortality(13and27%,respectively,bothstatisticallysignificant)(59).

Resultsofthreelargetrials(ACCORD,ADVANCE,andVADT)suggestednosignificantreduction

inCVDoutcomeswithintensiveglycemiccontrolinthesepopulations,whohadmore

advanceddiabetesthanUKPDSparticipants.Detailsofthesethreestudiesarereviewedextensively

inarecentADApositionstatement(70).

The


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glycemiccontrolarmofACCORDwashaltedearlyduetothefindingofanincreasedrateofmortalityintheintensivearmcomparedwith

thestandardarm(1.41%vs.1.14%peryear;HR

1.22[95%

CI1.01to1.46]);withasimilarincreaseincardiovasculardeaths.Theprimary

outcomeofACCORD(MI,stroke,orcardiovasculardeath)waslower


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intheintensiveglycemiccontrolgroup,duetoareductioninnonfatalMI,butthisreductionwasnotstatisticallysignificantwhenthestudywas

terminated(65).Thepotentialcauseofexcessdeathsintheintensivegroupof

theACCORDhasbeendifficulttopinpoint.Exploratoryanalysesofthemortalityfindings

ofACCORD(evaluatingvariablesincludingweightgain,useofany


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specificdrugordrugcombination,andhypoglycemia)werereportedlyunabletoidentifyaclear

explanationfortheexcessmortalityintheintensive

arm.TheACCORDinvestigatorssubsequentlypublishedadditionalanalysesshowingnoincreaseinmortality

intheintensivearmparticipantswhoachievedA1Clevels7%orinthose

wholoweredtheirA1Cquicklyaftertrialenrollment.Infact,


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theconversewasobservedthoseathighestriskformortalitywereparticipantsintheintensivearmwiththehighestA1Clevels(71).

TheprimaryoutcomeofADVANCEwasacombinationofmicrovascularevents(nephropathyand

retinopathy)andmajoradversecardiovascularevents(MI,stroke,andcardiovasculardeath).Intensiveglycemic

controlsignificantlyreducedtheprimaryendpoint,althoughthiswas


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duetoasignificantreductioninthemicrovascularoutcome,primarilydevelopmentofmacroalbuminuria,withnosignificantreductioninthemacrovascularoutcome.Therewasno

differenceinoverallorcardiovascularmortalitybetweentheintensivecomparedwiththestandard

glycemiccontrolarms(62).

TheVADTrandomizedparticipantswithtype2

diabetesuncontrolledoninsulinormaximaldoseoralagents(median


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entryA1C9.4%)toastrategyofintensiveglycemiccontrol(goalA1C

6.0%)orstandardglycemiccontrol,withaplannedA1Cseparation

ofatleast1.5%.TheprimaryoutcomeoftheVADTwasacomposite

ofCVDevents.Thecumulativeprimaryoutcomewasnonsignificantlylowerintheintensive

arm(60).UnliketheUKPDS,whichwascarriedoutin


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patientswithnewlydiagnoseddiabetes,allthreeoftherecenttype2cardiovasculartrialswereconductedinparticipantswithestablisheddiabetes(meanduration811

years)andeitherknownCVDormultipleriskfactors,suggestingthepresenceof

establishedatherosclerosis.Subsetanalysesofthethreetrialssuggestedasignificantbenefitof

intensiveglycemiccontrolonCVDinparticipantswithshorterduration


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ofdiabetes,lowerA1Catentry,and/ororabsenceofknownCVD.TheDCCT-EDICstudyandthelong-termfollow-upoftheUKPDScohortboth

suggestthatintensiveglycemiccontrolinitiatedsoonafterdiagnosisofdiabetesinpatients

withalowerlevelofCVDriskmayimpartlong-termprotectionfromCVD

events.Asisthecasewithmicrovascularcomplications,itmay


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bethatglycemiccontrolplaysagreaterrolebeforemacrovasculardiseaseiswelldevelopedandminimalornorolewhenitisadvanced.Consistent

withthis

concept,datafromanancillarystudyoftheVADT

demonstratedthatintensiveglycemiccontrolwasquiteeffectiveinreducingCVDeventsin

individualswithlessatherosclerosisatbaseline(assessedbycoronarycalcium)


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butnotinpersonswithmoreextensivebaselineatherosclerosis(72).

Theevidenceforacardiovascularbenefitofintensiveglycemiccontrolprimarilyrests

onlong-termfollow-upofstudycohortstreatedearlyinthecourseoftype

1andtype2diabetesandsubsetanalysesofACCORD,ADVANCE,andVADT.

Arecentgroup-levelmetaanalysisofthelatterthreetrialssuggests


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thatglucoseloweringhasamodest(9%)butstatisticallysignificantreductioninmajorCVDoutcomes,primarilynonfatalMI,withnosignificanteffectonmortality.

AprespecifiedsubgroupanalysissuggestedthatmajorCVDoutcomereductionoccurredinpatients

withoutknownCVDatbaseline(HR0.84[95%CI0.740.94])(73).

Conversely,themortalityfindingsinACCORDandsubgroupanalysesof


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VADTsuggestthatthepotentialrisksofveryintensiveglycemiccontrolmayoutweighitsbenefitsinsomepatients,suchasthosewithverylong

durationofdiabetes,knownhistoryofseverehypoglycemia,advancedatherosclerosis,andadvancedage/frailty.

Certainly,providersshouldbevigilantinpreventingseverehypoglycemiainpatientswithadvanced

diseaseandshouldnotaggressivelyattempttoachievenear-normalA1C


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levelsinpatientsinwhomsuchatargetcannotbereasonablyeasilyandsafelyachieved.

Recommendedglycemicgoalsformanynonpregnantadults

areshowninTable10.TherecommendationsarebasedonthoseforA1C

values,withlistedbloodglucoselevelsthatappeartocorrelatewithachievementof

anA1Cof7%.Less-stringenttreatmentgoalsmaybeappropriate


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foradultswithlimitedlifeexpectanciesoradvancedvasculardisease.GlycemicgoalsforchildrenareprovidedinVII.A.1.a.Glycemiccontrol.Severeorfrequenthypoglycemia

isanabsoluteindicationforthemodificationoftreatmentregimens,includingsettinghigher

glycemicgoals.

Theissueofpre-versuspostprandialSMBGtargetsiscomplex

(74).Elevatedpostchallenge(2-hOGTT)glucosevalueshavebeenassociated


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withincreasedcardiovascularriskindependentofFPGinsomeepidemiologicalstudies.Indiabeticsubjects,somesurrogatemeasuresofvas

S20DIABETESCARE,

VOLUME34,SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatementTable10Summaryofglycemicrecommendationsformanynonpregnantadultswithtype1diabetesconsistsofthefollowingdiabetescomponents:1)use

ofmultipledosein

A1CPreprandialcapillaryplasmaglucosePeakpostprandial

capillaryplasmaglucose

Goalsshouldbeindividualizedbasedon*:

durationofdiabetesage/lifeexpectancycomorbidconditions


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knownCVDoradvancedmicrovascularcomplicationshypoglycemiaunawarenessindividualpatientconsiderationsMoreorlessstringentglycemicgoalsmaybeappropriatefor

individualpatients.PostprandialglucosemaybetargetedifA1Cgoalsarenot

metdespitereachingpreprandialglucosegoals.7.0%*70130mg/dl*(3.97.2mmol/l)180mg/dl*

(10.0mmol/l)

Postprandialglucosemeasurementsshouldbemade


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12hafterthebeginningofthemeal,generallypeak

levelsinpatientswithdiabetes.

cularpathology,suchasendothelial

dysfunction,arenegativelyaffectedbypostprandialhyperglycemia(75).Itisclearthatpostprandial

hyperglycemia,likepreprandialhyperglycemia,contributestoelevatedA1Clevels,withitsrelativecontribution

beinghigheratA1Clevelsthatarecloserto7%.


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However,outcomestudieshaveclearlyshownA1Ctobetheprimarypredictorofcomplications,andlandmarkglycemiccontroltrialssuchastheDCCTand

UKPDSreliedoverwhelminglyonpreprandialSMBG.Additionally,arandomizedcontrolledtrialinpatients

withknownCVDfoundnoCVDbenefitofinsulinregimenstargetingpostprandialglucose

comparedwithtargetingpreprandialglucose(76).Areasonablerecommendationfor


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postprandialtestingandtargetsisthatforindividualswhohavepremealglucosevalueswithintargetbuthaveA1Cvaluesabovetarget,monitoringpostprandialplasma

glucose(PPG)12hafterthestartofthemealandtreatmentaimed

atreducingPPGvaluesto180mg/dlmayhelplowerA1C.

AsregardsgoalsforglycemiccontrolforwomenwithGDM,


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recommendationsfromtheFifthInternationalWorkshop-ConferenceonGestationalDiabetes(77)weretotargetmaternalcapillaryglucoseconcentrationsof:

Preprandial95

mg/dl(5.3mmol/l)andeither1-hpostmeal140mg/dl(7.8mmol/l)or

2-hpostmeal120mg/dl(6.7mmol/l)Forwomenwithpreexisting

type1ortype2diabeteswhobecomepregnant,a


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recentconsensusstatement(78)recommendedthefollowingasoptimalglycemicgoals,iftheycanbeachievedwithoutexcessivehypoglycemia:

.premeal,bedtime,

andovernightglucose6099mg/dl(3.35.4mmol/l).peakpostprandialglucose100129

mg/dl(5.47.1mmol/l).A1C6.0%D.Pharmacologicandoverallapproachestotreatment1.

Therapyfortype1diabetesTheDCCTclearlyshowedthat


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intensiveinsulintherapy(threeormoreinjectionsperdayofinsulin,orcontinuoussubcutaneousinsulininfusion(CSII)(insulinpumptherapy)wasakeypart

ofimprovedglycemiaandbetteroutcomes(47,68).Atthetimeofthestudy,

therapywascarriedoutwithshort-andintermediate-actinghumaninsulins.Despitebettermicrovascular

outcomes,intensiveinsulintherapywasassociatedwithahighrate


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inseverehypoglycemia(62episodesper100patient-yearsoftherapy).SincethetimeoftheDCCT,anumberofrapid-actingandlong-actinginsulin

analogshavebeendeveloped.Theseanalogsareassociatedwithlesshypoglycemiawithequal

A1C-loweringintype1diabetes(79,80).

Therefore,recommendedtherapyfor

sulininjections(threetofourinjectionsperdayof


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basalandprandialinsulin)orCSIItherapy;2)matchingofprandialinsulintocarbohydrateintake,premealbloodglucose,andanticipatedactivity;and3)for

manypatients(especiallyifhypoglycemiaisaproblem),useofinsulinanalogs.There

areexcellentreviewsavailablethatguidetheinitiationandmanagementofinsulintherapy

toachievedesiredglycemicgoals(3,79,81).

Becauseof


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theincreasedfrequencyofotherautoimmunediseasesintype1diabetes,screeningforthyroiddysfunction,vitaminB12deficiency,orceliacdiseaseshouldbeconsidered

basedonsignsandsymptoms.Periodicscreeninginabsenceofsymptomshasbeen

recommended,buttheeffectivenessandoptimalfrequencyareunclear.

2.Therapy

fortype2diabetesTheADAandtheEASDpublished


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anexpertconsensusstatementontheapproachtomanagementofhyperglycemiainindividualswithtype2diabetes(82).Highlightsofthisapproachare:intervention

atthetimeofdiagnosiswithmetforminincombinationwithlifestylechanges(MNT

andexercise)andcontinuingtimelyaugmentationoftherapywithadditionalagents(includingearly

initiationofinsulintherapy)asameansofachievingand


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maintainingrecommendedlevelsofglycemiccontrol(i.e.,A1C7%formostpatients).AsA1Ctargetsarenotachieved,treatmentintensificationisbasedonthe

additionofanotheragentfromadifferentclass.Theoverallobjectiveisto

achieveandmaintainglycemiccontrolandtochangeinterventionswhentherapeuticgoalsare

notbeingmet.

Thealgorithmtookintoaccount


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theevidenceforA1C-loweringoftheindividualinterventions,theiradditiveeffects,andtheirexpense.Theprecisedrugsusedandtheirexactsequencemaynot

beasimportantasachievingandmaintainingglycemictargetssafely.Medicationsnotincluded

intheconsensusalgorithm,owingtolessglucose-loweringeffectiveness,limitedclinicaldata,and/or

relativeexpense,stillmaybeappropriatechoicesinindividualpatients


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toachieveglycemicgoals.Initiationofinsulinattimeofdiagnosisisrecommendedforindividualspresentingwithweightlossorotherseverehyperglycemicsymptoms

orsigns.

care.diabetesjournals.orgDIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011

S21


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E.Diabetesself-managementeducationRecommendations

.Peoplewithdiabetesshouldreceivediabetesself-managementeducation(DSME)

accordingtonationalstandardswhentheirdiabetesisdiagnosedandasneededthereafter.

(B).Effectiveself-managementandqualityoflifearethekeyoutcomesof

DSMEandshouldbemeasuredandmonitoredaspartof


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care.(C).DSMEshouldaddresspsychosocialissues,sinceemotionalwell-beingisassociatedwithpositivediabetesoutcomes.(C).BecauseDSMEcanresultin

cost-savingsandimprovedoutcomes(B),DSMEshouldbeadequatelyreimbursedbythird-party

payors.(E)DSMEisanessentialelementofdiabetescare(8388),andnational

standardsforDSME(89)arebasedonevidenceforits


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benefits.Educationhelpspeoplewithdiabetesinitiateeffectiveself-managementandcopewithdiabeteswhentheyarefirstdiagnosed.OngoingDSMEandsupportalsohelp

peoplewithdiabetesmaintaineffectiveself-managementthroughoutalifetimeofdiabetesasthey

facenewchallengesandtreatmentadvancesbecomeavailable.DSMEhelpspatientsoptimizemetabolic

control,preventandmanagecomplications,andmaximizequalityoflife


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inacost-effectivemanner(90).

DSMEistheongoingprocessoffacilitatingtheknowledge,skill,andabilitynecessaryfordiabetesself-care.This

processincorporatestheneeds,goals,andlifeexperiencesofthepersonwithdiabetes.

TheoverallobjectivesofDSMEaretosupportinformeddecision-making,self-carebehaviors,problem-solving,

andactivecollaborationwiththehealthcareteamtoimprove


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clinicaloutcomes,healthstatus,andqualityoflifeinacost-effectivemanner(89).

CurrentbestpracticeofDSMEisaskills-basedapproach

thatfocusesonhelpingthosewithdiabetestomakeinformedself-managementchoices.DSME

haschangedfromadidacticapproachfocusingonprovidinginformationtomoretheoretically

basedempowermentmodelsthatfocusonhelpingthosewithdiabetes


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makeinformedself-managementdecisions.Careofdiabeteshasshiftedtoanapproachthatismorepatientcenteredandplacesthepersonwithdiabetesand

hisorherfamilyatthecenterofthecare

model

workingincollaborationwithhealthcareprofessionals.Patient-centeredcareisrespectfulof

andresponsivetoindividualpatientpreferences,needs,andvaluesand


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ensuresthatpatientvaluesguidealldecisionmaking(91).

EvidenceforthebenefitsofDSME

Multiplestudieshavefoundthat

DSMEisassociatedwithimproveddiabetesknowledgeandimprovedself-carebehavior(83),improved

clinicaloutcomessuchaslowerA1C(84,85,87,88,92),lowerself-reportedweight(83),improvedquality

oflife(86,93),healthycoping(94),andlowercosts(95).


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BetteroutcomeswerereportedforDSMEinterventionsthatwerelongerandincludedfollow-upsupport(83,9699),thatwereculturally(100,101)andageappropriate(102,103)and

tailoredtoindividualneedsandpreferences,andthataddressedpsychosocialissuesandincorporated

behavioralstrategies(83,87,104106).Bothindividualandgroupapproacheshavebeenfoundeffective(107110).

Thereisgrowingevidencefortheroleofcommunityhealth


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workersandpeer(111,112)andlayleaders(113)indeliveringDSMEandsupportinadditiontothecoreteam(114).

Diabeteseducation

isassociatedwithincreaseduseofprimaryandpreventiveservicesandloweruse

ofacute,inpatienthospitalservices(95).Patientswhoparticipateindiabeteseducationare

morelikelytofollowbestpracticetreatmentrecommendations,particularlyamong


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theMedicarepopulation,andhavelowerMedicareandcommercialclaimcosts(115).

NationalstandardsforDSME

NationalstandardsforDSME

aredesignedtodefinequalityDSMEandtoassistdiabeteseducatorsina

varietyofsettingstoprovideevidence-basededucation(89).Thestandards,mostrecentlyrevised

in2007,arereviewedandupdatedevery5yearsby


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ataskforcerepresentingkeyorganizationsinvolvedinthefieldofdiabeteseducationandcare.

ReimbursementforDSME

DSME,when

providedbyaprogramthatmeetsthenationalstandardsforDSMEandis

recognizedbytheADAorotherapprovalbodies,isreimbursedaspartofthe

MedicareprogramasoverseenbytheCentersforMedicareand


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MedicaidServices(CMS)(www.cms.hhs.gov/DiabetesSelfManagement).DSMEisalsocoveredbyagrowingnumberofotherhealthinsuranceplans.

F.Medicalnutritiontherapy

Generalrecommendations

.Individualswhohaveprediabetesordiabetesshouldreceive

individualizedmedicalnutritiontherapy(MNT)asneededtoachievetreatmentgoals,preferablyprovided

byaregistereddietitianfamiliarwiththecomponentsofdiabetes


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MNT.(A).BecauseMNTcanresultincost-savingsandimprovedoutcomes(B),MNTshouldbeadequatelycoveredbyinsuranceandotherpayors.(E)

Energybalance,overweight,andobesity

.Inoverweightandobeseinsulin-

resistantindividuals,modestweightlosshasbeenshowntoreduceinsulinresistance.Thus,

weightlossisrecommendedforalloverweightorobeseindividuals


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whohaveorareatriskfordiabetes.(A).Forweightloss,eitherlow-carbohydrate,low-fatcalorie-restricted,orMediterraneandietsmaybeeffectivein

theshort-term(upto2years).(A).Forpatientsonlow-carbohydrate

diets,monitorlipidprofiles,renalfunction,andproteinintake(inthosewithnephropathy),

andadjusthypoglycemictherapyasneeded.(E).Physicalactivity


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andbehaviormodificationareimportantcomponentsofweightlossprogramsandaremosthelpfulinmaintenanceofweightloss.(B)Recommendationsforprimaryprevention

ofdiabetes

.Amongindividualsathighriskfordevelopingtype

2diabetes,structuredprogramsthatemphasizelifestylechangesthatincludemoderateweightloss

(7%bodyweight)andregularphysicalactivity(150min/week),with


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dietarystrategiesincludingreducedcaloriesandreducedintakeofdietaryfat,canreducetheriskfordevelopingdiabetesandarethereforerecommended.(A).

Individualsathighriskfortype2diabetesshouldbeencouragedtoachieve

theU.S.DepartmentofAgriculture(USDA)recommendationfordietaryfiber(14gfiber/1,000

kcal)andfoodscontainingwholegrains(one-halfofgrainintake).


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(B)S22DIABETESCARE,VOLUME34,SUPPLEMENT1,JANUARY2011care.diabetesjournals.org


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PositionStatement

Recommendationsformanagementofdiabetes

Macronutrientsindiabetesmanagement

.Thebestmixofcarbohydrate,

protein,andfatmaybeadjustedtomeetthemetabolicgoalsandindividual

preferencesofthepersonwithdiabetes.(E).Monitoringcarbohydrate,whetherbycarbohydrate

counting,choices,orexperience-basedestimation,remainsakeystrategy


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inachievingglycemiccontrol.(A).Forindividualswithdiabetes,theuseoftheglycemicindexandglycemicloadmayprovideamodestadditional

benefitforglycemiccontroloverthatobservedwhentotalcarbohydrateisconsideredalone.

(B).Saturatedfatintakeshouldbe7%oftotalcalories.(A).

ReducingintakeoftransfatlowersLDLcholesterolandincreases


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HDLcholesterol(A),thereforeintakeoftransfatshouldbeminimized.(E)Othernutritionrecommendations

.Ifadultswithdiabeteschooseto

usealcohol,dailyintakeshouldbelimitedtoamoderateamount(onedrink

perdayorlessforadultwomenandtwodrinksperdayor

lessforadultmen).(E).Routinesupplementationwithantioxidants,


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suchasvitaminsEandCandcarotene,isnotadvisedbecauseoflackofevidenceofefficacyandconcernrelatedtolong-termsafety.

(A).Individualizedmealplanningshouldincludeoptimizationoffoodchoicestomeet

recommendeddietaryallowance(RDA)/dietaryreferenceintake(DRI)forallmicronutrients.(E)MNTis

anintegralcomponentofdiabetesprevention,management,andself-management


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education.Inadditiontoitsroleinpreventingandcontrollingdiabetes,ADArecognizestheimportanceofnutritionasanessentialcomponentofanoverall

healthylifestyle.Afullreviewoftheevidenceregardingnutritioninpreventingand

controllingdiabetesanditscomplicationsandadditionalnutrition-relatedrecommendationscanbefound

intheADApositionstatement,NutritionRecommendationsandInterventionsfor


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Diabetes,publishedin2007andupdatedfor2008(116).Achievingnutrition-relatedgoalsrequiresacoordinatedteameffortthatincludestheactivein

volvementofthepersonwithprediabetesordiabetes.Becauseofthecomplexity

ofnutritionissues,itisrecommendedthataregistereddietitianwhoisknowledgeable

andskilledinimplementingnutritiontherapyintodiabetesmanagementand


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educationbetheteammemberwhoprovidesMNT.

Clinicaltrials/outcomestudiesofMNThavereporteddecreasesinA1Cat36monthsranging

from0.25%to2.9%withhigherreductionsseenintype2diabetesof

shorterduration.MultiplestudieshavedemonstratedsustainedimprovementsinA1Cat12months

andlongerwhenanRegisteredDietitianprovidedfollow-upvisitsranging


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frommonthlytothreesessionsperyear(117124).StudiesinnondiabeticpeoplesuggestthatMNTreducesLDLcholesterolby1525mg/dlupto

16%(125)andsupportaroleforlifestylemodificationintreatinghypertension(125,126).

Becauseoftheeffectsofobesityoninsulinresistance,weightloss

isanimportanttherapeuticobjectiveforoverweightorobeseindividuals


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withprediabeteso

Standards of Medical Care in Diabetes 2011

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