Wisconsin essential diabetes mellitus care guidelines.

Concern	Care/Test	Frequency
General Recommendations for Care	Perform diabetes-focused visit Review management plan; assess barriers and goals Assess physical activity level Assess nutrition/weight/body mass index (BMI)/growth	Type 1: Every 3 months* Type 2: Every 3-6 months* Each focused visit; revise as needed Each focused visit Each focused visit
Self-Management Education	Refer to diabetes educator, preferably a certified diabetes educator (CDE) in an American Diabetes Association (ADA) Recognized Program; curriculum to include the ten key areas of the national standards	At diagnosis, then every 6-12 months, or more as needed
Medical Nutrition Therapy	Refer for medical nutrition therapy (MNT) provided by a registered dietician (RD), preferably one who is also a certified diabetes educator	At diagnosis or first referral to RD: 3 to 4 visits, completed in 3 to 6 months; then, annually. RD determines additional visits based on needs/goals.
Glycemic Control	Check A1c; goal: <7.0% (always individualize) (ADA recognizes goal of <7.0%) (American Association of Clinical Endocrinologists [AACE] recognizes goal of <6.5%) Review goals, medications, side effects, and frequency of hypoglycemia Assess self-blood glucose monitoring schedule	Type 1: Every 3 months* Type 2: Every 3-6 months* Each focused visit Each focused visit, 2-4 times/day, or as recommended
Cardiovascular Care	Check fasting lipid profile Adult goals: Total Cholesterol <200 mg/dL Triglycerides <150 mg/dL High-density lipoprotein (HDL) >40 mg/dL (men) HDL >50 mg/dL (women) Non-HDL (Cholesterol) <130 mg/dL Low-density lipoprotein (LDL) <100 mg/dL (optimal goal) LDL <70 mg/dL (for very high risk) Start statin with ongoing lifestyle changes Check blood pressure Adult goal: <130/80 mmHg Assess smoking/tobacco use status Start aspirin prophylaxis (unless contraindicated)	Children: After age 2 but before age 10. Repeat annually if abnormal, repeat in 3‑5 years if normal. Adults: Annually. If abnormal, follow National Cholesterol Education Program (NCEP) III guidelines. Adults with cardiovascular disease (CVD); Age >40 yrs with one or more risk factors for CVD Children: Each focused visit; follow National High Blood Pressure Education Program recommendations for Children and Adolescents Adults: Each focused visit Each visit; (5As: Ask, Advise, Assess, Assist; Arrange) Age >40 yrs with diabetes; Age <40 yrs, individualize based on risk
Kidney Care	Check albumin/creatinine ratio using a random urine sample, also called urine microalbumin/creatinine ratio Check serum creatinine and estimated glomerular filtration rate (GFR) Perform routine urinalysis	Type 1: At puberty or after 5 years duration, then annually Type 2: At diagnosis, then annually At diagnosis, then annually At diagnosis, then as indicated
Eye Care	Dilated eye exam by an ophthalmologist or optometrist	Type 1: If age >10, within 3-5 years of onset, then annually Type 2: At diagnosis, then annually; two exceptions exist
Neuropathies and Foot Care	Assess/screen for neuropathy (autonomic/distal symmetric polyneuropathy [DPN]) Visual inspection of feet with shoes and socks off Perform comprehensive lower extremity/foot exam (use monofilament and tuning fork) Screen for peripheral vascular disease (PVD) (consider ankle-brachial index [ABI])	Type 1: Five years after diagnosis, then annually Type 2: At diagnosis, then annually Each focused visit; stress daily self-exam At diagnosis, then annually At diagnosis, then annually
Oral Care	Inspect gums and teeth for signs of periodontal disease Dental exam by general dentist or periodontal specialist	At diagnosis, then each focused visit At diagnosis, then every 6 months (if dentate) and every 12 months (if edentate
Emotional/Sexual Health Care	Assess emotional health; screen for depression Assess sexual health concerns	Each focused visit Each focused visit
Immunizations	Provide influenza vaccine Provide pneumococcal vaccine	Annually, if age >6 months Once; then per Advisory Committee on Immunization Practices
Preconception and Pregnancy Care	Provide preconception counseling/assessment Assess contraception/discuss family planning Assess risk for gestational diabetes mellitus (GDM) Screen for GDM Screen for Type 2 diabetes post-GDM	3-4 months prior to conception At diagnosis and each focused visit At first prenatal visit (if high risk, screen immediately for GDM) At 24-28 weeks gestation or earlier if high risk At 6-12 weeks postpartum, then annually
Identification and Diagnosis of Pre-diabetes and Type 2 Diabetes	Perform fasting plasma glucose test or oral glucose tolerance test	Test all adults >age 45 (see original guideline document for testing of Type 2 diabetes in children and adolescents); if normal and person has no risk factors, retest in 3 years or less.

Concern

Care/Test

Frequency

General Recommendations for Care

Perform diabetes-focused visit
Review management plan; assess barriers and goals
Assess physical activity level
Assess nutrition/weight/body mass index (BMI)/growth

Type 1: Every 3 months*

Type 2: Every 3-6 months*

Each focused visit; revise as needed

Each focused visit

Each focused visit

Self-Management Education

Refer to diabetes educator, preferably a certified diabetes educator (CDE) in an American Diabetes Association (ADA) Recognized Program; curriculum to include the ten key areas of the national standards

At diagnosis, then every 6-12 months, or more as needed

Medical Nutrition Therapy

Refer for medical nutrition therapy (MNT) provided by a registered dietician (RD), preferably one who is also a certified diabetes educator

At diagnosis or first referral to RD: 3 to 4 visits, completed in 3 to 6 months; then, annually. RD determines additional visits based on needs/goals.

Glycemic Control

Check A1c; goal: <7.0% (always individualize)
(ADA recognizes goal of <7.0%)
(American Association of Clinical Endocrinologists [AACE] recognizes goal of <6.5%)
Review goals, medications, side effects, and frequency of hypoglycemia
Assess self-blood glucose monitoring schedule

Type 1: Every 3 months*

Type 2: Every 3-6 months*

Each focused visit

Each focused visit, 2-4 times/day, or as recommended

Cardiovascular Care

Check fasting lipid profile

Adult goals:

Total Cholesterol <200 mg/dL

Triglycerides <150 mg/dL

High-density lipoprotein (HDL) >40 mg/dL (men)

HDL >50 mg/dL (women)

Non-HDL (Cholesterol) <130 mg/dL

Low-density lipoprotein (LDL) <100 mg/dL (optimal goal)

LDL <70 mg/dL (for very high risk)

Start statin with ongoing lifestyle changes
Check blood pressure
Adult goal: <130/80 mmHg
Assess smoking/tobacco use status
Start aspirin prophylaxis (unless contraindicated)

Children: After age 2 but before age 10. Repeat annually if abnormal, repeat in 3‑5 years if normal.

Adults: Annually. If abnormal, follow National Cholesterol Education Program (NCEP) III guidelines.

Adults with cardiovascular disease (CVD); Age >40 yrs with one or more risk factors for CVD

Children: Each focused visit; follow National High Blood Pressure Education Program recommendations for Children and Adolescents

Adults: Each focused visit

Each visit; (5As: Ask, Advise, Assess, Assist; Arrange)

Age >40 yrs with diabetes; Age <40 yrs, individualize based on risk

Kidney Care

Check albumin/creatinine ratio using a random urine sample, also called urine microalbumin/creatinine ratio
Check serum creatinine and estimated glomerular filtration rate (GFR)
Perform routine urinalysis

Type 1: At puberty or after 5 years duration, then annually

Type 2: At diagnosis, then annually

At diagnosis, then annually

At diagnosis, then as indicated

Eye Care

Dilated eye exam by an ophthalmologist or optometrist

Type 1: If age >10, within 3-5 years of onset, then annually

Type 2: At diagnosis, then annually; two exceptions exist

Neuropathies and Foot Care

Assess/screen for neuropathy (autonomic/distal symmetric polyneuropathy [DPN])
Visual inspection of feet with shoes and socks off
Perform comprehensive lower extremity/foot exam (use monofilament and tuning fork)
Screen for peripheral vascular disease (PVD) (consider ankle-brachial index [ABI])

Type 1: Five years after diagnosis, then annually

Type 2: At diagnosis, then annually

Each focused visit; stress daily self-exam

At diagnosis, then annually

At diagnosis, then annually

Oral Care

Inspect gums and teeth for signs of periodontal disease
Dental exam by general dentist or periodontal specialist

At diagnosis, then each focused visit

At diagnosis, then every 6 months (if dentate) and every 12 months (if edentate

Emotional/Sexual Health Care

Assess emotional health; screen for depression
Assess sexual health concerns

Each focused visit

Each focused visit

Immunizations

Provide influenza vaccine
Provide pneumococcal vaccine

Annually, if age >6 months

Once; then per Advisory Committee on Immunization Practices

Preconception and Pregnancy Care

Provide preconception counseling/assessment
Assess contraception/discuss family planning
Assess risk for gestational diabetes mellitus (GDM)
Screen for GDM
Screen for Type 2 diabetes post-GDM

3-4 months prior to conception**

At diagnosis and each focused visit**

At first prenatal visit (if high risk, screen immediately for GDM)**

At 24-28 weeks gestation or earlier if high risk**

At 6-12 weeks postpartum, then annually

Identification and Diagnosis of Pre-diabetes and Type 2 Diabetes

Perform fasting plasma glucose test or oral glucose tolerance test

Test all adults >age 45 (see original guideline document for testing of Type 2 diabetes in children and adolescents); if normal and person has no risk factors, retest in 3 years or less.

Revision Workgroup Members: Sue Backes, RN, BS, AE-C, CCM, Physicians Plus Insurance Corporation; Dory Blobner, RN, MS, CDE, Diabetes Educators International; Erika Brown, CSW, Wisconsin Dental Association, Inc.; Mary Bruskewitz, RN, BC-ADM, UW Health Diabetes Clinic; Jenny Camponeschi, MS, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Pat Celek, RN, CDE, Aurora Medical Group, Wisconsin Association for Perinatal Care Preconception and Prenatal Care Committee; April Eddy, RN, CNS, CDE (APNP) Meriter Center for Perinatal Care; Diane Elson, MD, University of Wisconsin Hospital and Clinics; Edwin Ferguson, MD, Section of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health; Joan Fisher, RN, CCM, CDE, MercyCare Health Plans; Pamela Geis, BA, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Irene Golembiewski, MA, Media Solutions, University of Wisconsin School of Medicine and Public Health; Dee Helgeson, RN, BSN, CDE, Reedsburg Physicians Group; Thomas Haupt, MS, Communicable Disease Epidemiology Section, Wisconsin Department of Health Services; Sue Hugl, RN, BSN, CDE, Diabetes & Endocrine Center, Froedtert & Medical College of Wisconsin; Anthony M. Iacopino, DMD, PhD, University of Manitoba Faculty of Dentistry; Jonathan B. Jaffery, MD, Department of Medicine, Section of Nephrology, University of Wisconsin School of Medicine and Public Health; Audrey Johnson, RN, MSN, CDE, Aurora Health Care; Bob Johnson, MD, Wisconsin Academy of Family Physicians, Western Wisconsin Medical Associates – River Falls Medical Clinic; Virginia Jordan, MS, RD, CDE, West Central Wisconsin Area Association of Diabetes Educators; Judith Kozminski, Media Solutions, University of Wisconsin School of Medicine and Public Health; Jennifer Keeley, MS, RD, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Pamela Kittleson, RPh, UW Medical Foundation; Christy Kreul, BS, CCP, Physicians Plus Insurance Corporation; Scott Krueger, RD, CD, CDE, Wisconsin Dietetic Association and Menominee Tribal Clinic; Leah Ludlum, RN, BSN, CDE, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Steven B. Magill, MD, PhD, Midwest Endocrinology Associates and Aurora Diabetes Care Initiative, St. Luke's Medical Center; Jason Mailhot, DMD, MS, Marquette University of School of Dentistry; Melissa Meredith, MD, University of Wisconsin Hospital and Clinics; Mary Jane Mihajlovic, RN, BSN, HN-BC, CHTP, Unity Health Plans Insurance Corporation, Nutrition and Physical Activity Program, Department of Health Services; Pamela Myhre, RN, BSN, CDE, University of Wisconsin School of Nursing; Jane Nelson Worel, MS, APNP, Women's Cardiovascular Wellness Program, Meriter Heart Hospital; Angela Nimsgern, MPH, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Roxanne Radich, APNP, CNS, CDE, Fox Valley Nephrology Partners, Inc., The Diabetes Management Center; Paul M. Reber, DO, Division of Endocrinology, Dean Health Systems; Thomas Repas, DO, FACP, FACE, CDE, Regional Medical Clinic – Endocrinology, Rapid City, SD; Kathleen Rickerl, BA, RN, Mental Health Center of Dane County; Tim Ringhand, RN, MPH, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Elaine Rosenblatt, MSN, FNP-BC, UW Medical Foundation; David A. Scheidt, OD, Wisconsin Optometric Association; Thomas S. Stevens, MD, Wisconsin Academy of Ophthalmology; Alisa Sunness, RD, CDE, UW Health and Nutrition Education; Gail Underbakke, MS, RD, CD, Preventive Cardiology Program, University of Wisconsin Hospital and Clinics; Denise Walbrandt Pigarelli, PharmD, BC-ADM, University of Wisconsin School of Pharmacy, William S. Middleton VA Memorial Hospital; Naomi Wedel, MS, RD, CDE, BC-ADM, Capitol Area and Surrounding Communities Association of Diabetes Educators; William Weis, DPM, FACFAS, CWS, Wisconsin Society of Podiatric Medicine; Susan Williams, RN, CDE, Wheaton Franciscan Healthcare – St. Francis Hospital; Deborah Patrick Wubben, MD, MPH, University of Wisconsin School of Medicine and Public Health and Physicians Plus Insurance Corporation; Kara Yaeger, RN, BSN, CDE, UW Health – West Diabetes Clinic

Advisory Group Members: Della Alvarez, MS, FNP, APNP SC Johnson, Inc.; Diane Anderson, MS, RN, BC-FNP, APNP, CDE Gateway Technical College; Lori Arnoldussen, RN ThedaCare Health System; Sue Backes, RN, BS, AE-C, CCM, Physicians Plus Insurance Corporation; Jill Ballard, MPH, CHES, Evidence-Based Prevention Programs; Erika Brown, CSW Wisconsin Dental Association, Inc.; Catheryn Brue, MA, Heart Disease and Stroke Prevention Program, Wisconsin Department of Health Services; Mary Bruskewitz, RN, BC-ADM, UW Health Diabetes Clinic; Mary Carlson, WPS Health Insurance; Mariaelena Chang Calhoun, MSN, Children's Speciality Group, Medical College of Wisconsin; Isa Chase, RN, MSN, CPNP, Wisconsin Association of School Nurses; Wendy Countryman, RN, CCM, COHN-S, CVE WEA Trust; Pam Crouse, MS, RN, Wisconsin Primary Health Care Association; Diane Elson, MD, University of Wisconsin Hospital and Clinics; Elizabeth Fayram, PhD, RN, UW-Milwaukee College of Nursing; Joan Fisher, RN, CCM, CDE, MercyCare Health Plans; Charlanne FitzGerald, MPH, University of Wisconsin Population Health Institute; Susan Garman, Wisconsin Institute for Public Health; Gary Goyke, Wisconsin Council of the Blind and Visually Impaired; Sharon Gray, RN, BSN, Aurora Health Care; Yvonne D. Greer, MPH, RD, CD, Adolescent Community Health Program, City of Milwaukee Health Department; Dean Groth, MS, Pfizer, Inc., Linda Guddie, RPh, Diabetes Assessment and Resource Team, Froedtert Hospital Pharmacy; Peter Hanson, MD, Peter Christensen Health Clinic; Kristin Hill, Great Lakes Inter-Tribal Council, Inc.; Kate Holzum, RN, BSN, CDE, Diabetes Program, Children's Hospital of Wisconsin; Cindy Huber, National Kidney Foundation of Wisconsin; Todd Hughes, Novo Nordisk, Inc.; Sue Hugl, RN, BSN, CDE, Diabetes & Endocrine Center, Froedtert & Medical College of Wisconsin; Bob Johnson, MD, Wisconsin Academy of Family Physicians, Western Wisconsin Medical Associates – River Falls Medical Clinic; Virginia Jordan, MS, RD, CD, CDE, West Central Wisconsin Area Association of Diabetes Educators; Penny Kasprzak, American Diabetes Association, Wisconsin Area; Gwen Klinkner, MS, RN, ADMCNS-BC, CDE, University of Wisconsin Hospital and Clinics; Stephen R. Knapp, ProMark Communications, Inc.; Joy Kobiske, RN, MSN, FNP, CDE, Northeast Wisconsin Association of Diabetes Educators; Kevin Kortsch, DPM, Wisconsin Society of Podiatric Medicine, Inc.; Christy Kreul, BS, CCP, Physicians Plus Insurance Corporation; Scott Krueger, RD, CD, CDE, Wisconsin Dietetic Association, Menominee Tribal Clinic; Jim Lazarz, Juvenile Diabetes Research Foundation; Rob London, Independent Private Practitioner; Jason Mailhot, DMD, MS; Marquette University of School of Dentistry; W. Curtis Marshall, Southeast Regional Office, Wisconsin Division of Public Health; Suzanne Matthew, PhD, Northern Wisconsin Area Health Education Center; Patricia McManus, PhD, Black Health Coalition of Wisconsin; Melissa Meredith, MD, University of Wisconsin Hospital and Clinics; Traci Meyer, MS, Froedtert & Community Health; Mary Jane Mihajlovic, RN, BSN, HN-BC, CHTP, Unity Health Plans Insurance Corporation; Christine Miller, RN, PhD, Ruth S. Coleman College of Nursing, Cardinal Stritch University; Paula J. Miller, RN, BA, Wisconsin Lions Foundation; Gail Morgan American Heart Association, Midwest Affiliate; Timothy A. Moureau, APRN, BC-GNP, BC-ADM, CDE, Oneida Nation Community Health Center; Pam Myhre, RN, BSN, CDE, University of Wisconsin School of Nursing; Michael Nelipovich, RhD, Office for the Blind and Visually Impaired, Wisconsin Department of Health Services; Victoria O'Brien, American Heart Association, Greater Midwest Affiliate; Daniel Patterson, RN, BSN, Managed Health Services Network Health Plan; Mary Pesik, RD, CD, Nutrition and Physical Activity Program, Wisconsin Department of Health Services; John Quinette, American Diabetes Association, Wisconsin Area; Dana Richardson, MHA, RN, Wisconsin Hospital Association; Ray Ropers, Wisconsin Lions Diabetes Focus Group, Wisconsin Lions Foundation; David A. Scheidt, OD, Wisconsin Optometric Association; Joie Scheuer, BSN, RN, CDE, Southeastern Wisconsin Association of Diabetes Educators; Cynthia Schlough, Wisconsin Collaborative for Healthcare Quality; Susan Schmitz, BSN, GlaxoSmithKline; Debbie Scullin, RN, Fort Health Care; Shirley Sharp, BS, MA, Milwaukee Urban League, Inc.; Liz Shelley, Wisconsin Lions Foundation; Sonya Sidky, Wisconsin Department of Employee Trust Funds; Kay Simmons, MA, MetaStar, Inc.; Terry Spears Barnett, MD, Cream City Medical Society; Elizabeth Spencer, RD, MS, CDE, West Central Wisconsin Area Association of Diabetes Educators; Thomas S. Stevens, MD, Wisconsin Academy of Ophthalmology and Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health; Jacqueline Terry, National Black Nurses Association, Milwaukee Chapter; Julie Thiel, RPh, Pharmacy Society of Wisconsin; Melissa Tobler, RN, BSN, Wachovia Insurance Services; Anne Trinh, Great Lakes Inter-Tribal Council, Inc.; Fanaye Turner, Milwaukee Area Health Education Center; Vaughn Vance WEA Trust; Kathy Verstegen, RN, Wisconsin Association of School Nurses, Denise Walbrandt Pigarelli, PharmD, BC-ADM, Pharmacy Society of Wisconsin, University of Wisconsin School of Pharmacy; Katie Walsh, RN, CDE Innovex; Naomi Wedel, MS, RD, CDE, BC-ADM, Capitol Area and Surrounding Communities Association of Diabetes Educators; Mark Wegner, MD, MPH, Bureau of Community Health Promotion, Wisconsin Department of Health Services; Debbie Woelfel, Northeast Wisconsin Association of Diabetes Educators, Deborah Patrick Wubben, MD, MPH, University of Wisconsin School of Medicine and Public Health and Physicians Plus Insurance Corporation; Chua Xiong, Brown County Health Department; Kara Yaeger, RN, BSN, CDE, UW Health – West Diabetes Clinic; Jessica Zuercher, RN, BSN, Gerald L. Ignace Indian Health Center

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