The evidence grading system (A-C, E) is defined at the end of the" Major Recommendations" field.
Diabetes Care
Initial Evaluation
A complete medical evaluation should be performed to classify the diabetes, detect the presence or absence of diabetes complications, review previous treatment and glycemic control in patients with established diabetes, assist in formulating a management plan, and provide a basis for continuing care. Laboratory tests appropriate to the evaluation of each patient's medical condition should be performed. A focus on the components of comprehensive care (see Table 7 in the original guideline document) will assist the health care team to ensure optimal management of the patient with diabetes.
Management
People with diabetes should receive medical care from a physician-coordinated team. Such teams may include, but are not limited to, physicians, nurse practitioners, physician's assistants, nurses, dietitians, pharmacists, and mental health professionals with expertise and a special interest in diabetes. It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care.
The management plan should be formulated as an individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team. A variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management. Implementation of the management plan requires that each aspect is understood and agreed on by the patient and the care providers and that the goals and treatment plan are reasonable. Any plan should recognize diabetes self-management education (DSME) as an integral component of care. In developing the plan, consideration should be given to the patient's age, school or work schedule and conditions, physical activity, eating patterns, social situation and personality, cultural factors, and presence of complications of diabetes or other medical conditions.
Glycemic Control
Assessment of Glycemic Control
Self-monitoring of Blood Glucose (SMBG)
- SMBG should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy. (A)
- For patients using less frequent insulin injections, noninsulin therapies, or medical nutrition therapy (MNT) alone, SMBG is useful in achieving glycemic goals. (E)
- To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
- When prescribing SMBG, ensure that patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and their ability to use data to adjust therapy. (E)
- Continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness. (E)
Glycated Hemoglobin Test (A1C)
- Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). (E)
- Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. (E)
- Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed (E)
Glycemic Goals
- Lowering A1C to an average of ~7% has clearly been shown to reduce microvascular and neuropathic complications of diabetes and, possibly, macrovascular disease. Therefore, the A1C goal for nonpregnant adults in general is <7%. (A)
- Epidemiologic studies have suggested an incremental (albeit, in absolute terms, a small) benefit to lowering A1C from 7% into the normal range. Therefore, the A1C goal for selected individual patients is as close to normal (<6%) as possible without significant hypoglycemia.(B)
- Less stringent A1C goals may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, children, individuals with comorbid conditions, and those with longstanding diabetes and minimal or stable microvascular complications. (E)
Summary of Glycemic Recommendations for Adults with Diabetes
| Hemoglobin (A1C) |
<7.0%* |
| Preprandial capillary plasma glucose |
70 to 130 mg/dL (3.9 to 7.2 mmol/L) |
| Peak postprandial capillary plasma glucose** |
<180 mg/dL (<10.0 mmol/L) |
Key concepts in setting glycemic goals:
- A1C is the primary target for glycemic control.
- Goals should be individualized based on:
- Duration of diabetes
- Pregnancy status
- Age
- Comorbid conditions
- Hypoglycemia unawareness
- Individual patient considerations
- More stringent glycemic goals (i.e., a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia.
- Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals.
|
*Referenced to a nondiabetic range of 4.0 to 6.0% using a Diabetes Control and Complications Trial (DCCT)-based assay.
**Postprandial glucose measurements should be made 1 to 2 hours after the beginning of the meal, generally peak levels in patients with diabetes.
Approach to Treatment
Therapy for Type 1 Diabetes
Recommended therapy for type 1 diabetes consists of the following components: 1) use of multiple dose insulin injections (3 to 4 injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII) therapy; 2) matching of prandial insulin to carbohydrate intake, premeal blood glucose, and anticipated activity; and 3) for many patients (especially if hypoglycemia is a problem), use of insulin analogs. There are excellent reviews available that guide the initiation and management of insulin therapy to achieve desired glycemic goals.
Therapy for Type 2 Diabetes
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes published a consensus statement on the approach to management of hyperglycemia in individuals with type 2 diabetes. Highlights of this approach are 1) Intervention at the time of diagnosis with metformin in combination with lifestyle changes (MNT and exercise) and 2) continuing, timely augmentation of therapy with additional agents (including early initiation of insulin therapy) as a means of achieving and maintaining recommended levels of glycemic control (i.e., A1C <7% for most patients). The overall objective is to achieve and maintain glycemic levels as close to the nondiabetic range as possible and to change interventions at as rapid a pace as titration of medications allows.
Initiation of insulin at time of diagnosis is recommended for individuals presenting with weight loss or other severe hyperglycemic symptoms or signs.
For a list of currently approved diabetes medications, see http://ndep.nih.gov/diabetes/pubs/Drug_tables_supplement.pdf.
Medical Nutrition Therapy
General Recommendations
- Individuals who have pre-diabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (B)
- MNT should be covered by insurance and other payors. (E)
Energy Balance, Overweight, and Obesity
- In overweight and obese insulin-resistant individuals, modest weight loss has been shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. (A)
- For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A)
- For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. (E)
- Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)
Primary Prevention of Diabetes
- Among individuals at high risk for developing type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended. (A)
- Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)
Dietary Fat Intake in Diabetes Management
- Saturated fat intake should be <7% of total calories. (A)
- Intake of trans fat should be minimized. (E)
Carbohydrate Intake in Diabetes Management
- Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experience-based estimation, remains a key strategy in achieving glycemic control. (A)
- For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone. (B)
Other Nutrition Recommendations
- Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the Food and Drug Administration (FDA). (A)
- If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for adult women and two drinks per day or less for adult men). (E)
- Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. (A)
- Benefit from chromium supplementation in people with diabetes or obesity has not been conclusively demonstrated and, therefore, cannot be recommended. (E)
Diabetes Self-Management Education (DSME)
- People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter. (B)
- Self-management behavior change is the key outcome of DSME and should be measured and monitored as part of care. (E)
- DSME should address psychosocial issues, since emotional well-being is strongly associated with positive diabetes outcomes. (C)
- DSME should be reimbursed by third-party payors. (E)
Physical Activity
- People with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50 to 70% of maximum heart rate). (A)
- In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance exercise three times per week. (A)
Psychosocial Assessment and Care
- Assessment of psychological and social situation should be included as an ongoing part of the medical management of diabetes. (E)
- Psychosocial screening and follow-up should include but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional) and psychiatric history. (E)
- Screen for psychosocial problems such as depression, anxiety, eating disorders, and cognitive impairment when adherence to the medical regimen is poor. (E)
When Treatment Goals Are Not Met
For a variety of reasons, some people with diabetes and their health care providers do not achieve the desired goals of treatment (see the table titled "Summary of glycemic recommendations for adults with diabetes", above). Intensification of the treatment regimen is suggested and may include assessment of barriers to adherence, including income; educational attainment; and competing demands, including those related to family responsibilities and family dynamics; culturally appropriate and enhanced DSME; co-management with a diabetes team; referral to a medical social worker for assistance with insurance coverage; change in pharmacological therapy; initiation of or increase in SMBG; more frequent contact with the patient; and referral to an endocrinologist.
Intercurrent Illness
The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis (DKA) or nonketotic hyperosmolar state, both of which are life-threatening conditions that require immediate medical care to prevent complications and death. Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose and (in ketosis-prone patients) urine or blood ketones. Marked hyperglycemia requires temporary adjustment of the treatment program and, if accompanied by ketosis, vomiting, or alteration in the level of consciousness, immediate interaction with the diabetes care team. The patient treated with noninsulin therapies or MNT alone may temporarily require insulin. Adequate fluid and caloric intake must be ensured. Infection or dehydration is more likely to necessitate hospitalization of the person with diabetes than the person without diabetes. The hospitalized patient should be treated by a physician with expertise in the management of diabetes. For further information on management of patients with hyperglycemia in the hospital, see the NGC summary of the ADA guideline Standards of medical care in diabetes. VIII. Diabetes care in specific settings. For further information on management of DKA or nonketotic hyperosmolar state, refer to the ADA position statement on hyperglycemic crises.
Hypoglycemia
- Glucose (15 to 20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If SMBG 15 min after treatment shows continued hypoglycemia, the treatment should be repeated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. (E)
- Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals. (E)
- Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. (B)
Immunization
- Annually provide an influenza vaccine to all diabetic patients >6 months of age. (C)
- Provide at least one lifetime pneumococcal vaccine for adults with diabetes. A one-time revaccination is recommended for individuals >65 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation. (C)
Definitions:
American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations
A
Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:
- Evidence from a well-conducted multicenter trial
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
- Compelling non-experimental evidence (i.e., "all or none" rule developed by the Center for Evidence Based Medicine at Oxford*)
Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including:
- Evidence from a well-conducted trial at one or more institutions
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
*Either all patients died before therapy and at least some survived with therapy, or some patients died without therapy and none died with therapy. Example: use of insulin in the treatment of diabetic ketoacidosis.
B
Supportive evidence from well-conducted cohort studies:
- Evidence from a well-conducted prospective cohort study or registry
- Evidence from a well-conducted prospective cohort study
- Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies, including:
- Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
- Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
- Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E
Expert consensus or clinical experience
