The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Periodic Assessment
Assessment should include:
- Weight, body mass index (BMI)1
- Blood pressure [A] (adult target of <130/80)
- Assess cardiovascular risks:
- Smoking, hypertension, dyslipidemia, sedentary lifestyle, obesity, stress, family history, age >40 years, gender
- Comprehensive foot exam (including monofilament testing annually) [B]
- Screen for depression [D]
- Dilated eye exam by ophthalmologist or optometrist [B], or digiscope [B]
Frequency
At least annually and more frequently as needed
Laboratory Tests
Tests should include:
- Hemoglobin A1C [D]
- Urine microalbumin measurement [D]
- Serum creatinine and calculated glomerular filtration rate (GFR) [D]
- Fasting lipid profile
Frequency
Hemoglobin A1C: 2 to 4 times annually based on individual therapeutic goal2; other tests at least annually
1BMI = weight (kg)/height squared (m2) or (pounds x 703)/inches2
2Develop or adjust the management plan to achieve normal or near-normal glycemia with an A1C goal of <7%. Less stringent treatment goals may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, very young children, or older adults, and individuals with comorbid conditions. More stringent treatment goals (i.e., a normal A1C <6%) for individual patients and in pregnancy.
Education, Counseling, and Risk Factor Modification
People with diabetes should receive medical care from a physician-coordinated team:
- Consider referral to diabetes educator if education not provided by physician or practice staff
- Education should include:
- Nutrition counseling, including role of weight in insulin resistance and importance of progress toward ideal body weight
- Role of self-monitoring of blood glucose in glycemic control [A]
- Cardiovascular risk reduction
- Smoking cessation intervention [B] and secondhand smoke avoidance [C]
- Regular physical activity [A]
- Self-care of feet [B]
- Preconception counseling [D]
- Encourage patients to receive dental care
Frequency
At diagnosis and as needed
Medical Recommendations
Care should focus on smoking, hypertension, lipids, and glycemic control:
- Treatment of hypertension using up to 3 or 4 anti-hypertensive medications to achieve adult target of <130 systolic [A] and <80 diastolic [B]
- Prescription of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) in patients with hypertension or albuminuria [A]3
- Statin therapy for primary prevention against macrovascular complications in patients with diabetes who are >age 40 or who have a low-density lipoprotein cholesterol (LDL-C) >100 mg/dL. [A]4
- Management of cardiovascular risk factors
- Assurance of appropriate immunization status (tetanus, diphtheria, pertussis, influenza, pneumococcal vaccine) [C]
- Anti-platelet therapy [A]: low dose aspirin daily for primary prevention in those at increased cardiovascular risk with type 1 [C] and type 2 [A] diabetes, unless contraindicated5
3Consider referral of patients with serum creatinine value >2.0 mg/dL (adult value) or persistent albuminuria to nephrologist for evaluation.
4Target LDL-C <100 mg/dL [B]. For patients with overt cardiovascular disease (CVD), a lower LDL-C goal of <70 mg/dL is an option [B].
5Aspirin therapy is not routinely recommended for patients under the age of 21 years because of the increased risk of Reye's syndrome.
Frequency
At each visit until therapeutic goals are achieved
Definitions:
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
