Physical and Emotional Assessment
Blood Pressure, Weight: Every visit. Blood pressure (BP) target goal <130/80 mmHg. For children: Add height, normal body mass index (BMI) for age, plot on 2001 Centers for Disease Control and Prevention (CDC) growth charts; blood pressure <90th percentile age standard.
Foot Exam (for adults): Thorough visual inspection every diabetes care visit; pedal pulses, neurological exam yearly.
Dilated Eye Exam (by trained expert): Type 1: Five years post diagnosis, then every year. Type 2: Shortly after diagnosis, then every year. Note: Internal quality assurance data may be used to support less frequent testing.
Depression: Probe for emotional/physical factors linked to depression yearly; treat aggressively with counseling, medication, and/or referral.
Dental: Exams at least twice yearly. Prophylaxis two to four times a year.
Lab Exam
A1C (Hemoglobin A1c): Quarterly, if treatment changes or if not meeting goals; One or two times/year if stable. Target goal <7.0% or <1% above lab norms. For children: Modify as necessary to prevent significant hypoglycemia.
Microalbuminuria (Albumin/Creatinine Ratio): Type 1: Begin with puberty once the duration of diabetes is more than five years unless proteinuria has been documented. Type 2: Begin at diagnosis, then every year unless proteinuria has been documented.
Blood Lipids (for adults): On initial visit, then yearly for adults. Target goals (mg/dL): cholesterol, triglycerides <150; low-density lipoproteins (LDL) <100; high-density lipoproteins (HDL) >40 for men; high-density lipoproteins >50 for women.
Self-Management Training
Management Principles and Complications: Initially and yearly: Assess knowledge of diabetes, medications, self-monitoring, acute/chronic complications, and problem-solving skills. Ongoing: Screen for problems with and barriers to self-care; assist patient to identify achievable self-care goals. For children: As appropriate for developmental stage.
Self-Glucose Monitoring: Type 1: Typically test four times a day. Type 2 and others: As needed to meet treatment goals.
Medical Nutrition Therapy (by trained expert): Initially: Assess needs/condition; assist patient in setting nutrition goals. Ongoing: Assess progress toward goals; identify problem areas.
Physical Activity: Initially and ongoing: Assess and prescribe physical activity based on patient's needs/condition.
Weight Management: Initially and ongoing: Must be individualized for patient.
Interventions
Preconception, Pregnancy, and Postpartum Counseling and Management: Consult with high-risk, multidisciplinary perinatal/neonatal programs and providers where available (e.g., California Diabetes and Pregnancy Program "Sweet Success"). For adolescents: Age appropriate counseling advisable, beginning with puberty.
Aspirin Therapy: 81 to 325 mg/day or 325 mg every other day in adults as primary and secondary prevention of cardiovascular disease, unless contraindicated.
Smoking Cessation: Screen, advise, access readiness to quit, and assist at every diabetes care visit, adjusting the frequency as appropriate to the patient's response. Refer to California Smokers' Helpline 1-800-NO-BUTTS.
Immunizations: Influenza and pneumococcal, per CDC recommendations.
Explanatory Notes
It is assumed that the following are routinely occurring in the medical setting:
- A history and physical appropriate for a person with diabetes are performed. Visits are sufficiently frequent to meet the patient's needs and treatment goals.
- Abnormal physical or laboratory findings result in appropriate and individualized interventions.
- Expert multi-disciplinary health professionals provide self-management training. For children/adolescents and their families, training from a diabetes team or team member with experience in child and adolescent diabetes is strongly recommended to begin at diagnosis.
- Physicians should consult current references for normal values and for appropriate treatment goal values, both for children and adults.
- Specialists should be consulted when patients are unable to achieve treatment goals in a reasonable time frame, when complications arise, or whenever the primary care physician deems it appropriate. Under similar circumstances, children/adolescents should be referred to specialists who have expertise in managing children and adolescents with diabetes.
Additional comments on specific items included in the guidelines:
Psychosocial assessment: Assess barriers to self-care: common environmental obstacles, cultural issues, beliefs and feelings about diabetes, disorders of eating and mood, life stresses, and substance use.
A1C (Hemoglobin A1c)/Self-Glucose Monitoring: Certification by the National Glycohemoglobin Standardization Program as traceable to the Diabetes Control Complications Trial (DCCT) reference ensures portability of A1C results. Verify that the laboratory is certified in this method. A1C target goals should be achieved gradually over time. Target goals should be less stringent for children, the elderly, and other fragile patients. Clinicians have found that making the patient aware of his/her A1C values and their significance helps motivate the patient toward improved glycemic control. This principle also applies to self-glucose monitoring. Target goals should be individualized for each patient.
Microalbuminuria: Screening is not needed if proteinuria has been documented. See Screening and Initial Management of Diabetic Microalbuminuria and Nephropathy algorithm in original guideline document.
Blood Lipids: Abnormal blood lipids are often under-treated. An active, progressive treatment and monitoring plan should be instituted.
Dental: Physicians are urged to recommend dental care as a part of basic diabetes care.
Children/Adolescents: For specific diabetes care recommendations see references in the original guideline document.
Aspirin (ASA): Women with diabetes are high risk for cardiovascular disease and therefore 81mg daily is indicated. Doses ASA >81mg daily have increased bleeding risk and no proven additional benefits.
