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S14 Diabetes Care Volume 37, Supplement 1, January 2014

Standards of Medical Care in American Diabetes Association

Diabetesd2014
Diabetes mellitus is a complex, chronic illness requiring continuous medical care
with multifactorial risk reduction strategies beyond glycemic control. Ongoing
patient self-management education and support are critical to preventing acute
complications and reducing the risk of long-term complications. Signicant
evidence exists that supports a range of interventions to improve diabetes
outcomes.
The American Diabetes Associations (ADAs) Standards of Care are intended to
provide clinicians, patients, researchers, payers, and other interested
individuals with the components of diabetes care, general treatment goals,
and tools to evaluate the quality of care. The Standards of Care
POSITION STATEMENT

recommendations are not intended to preclude clinical judgment and must be


applied in the context of excellent clinical care and with adjustments for
individual preferences, comorbidities, and other patient factors. For
more detailed information about management of diabetes, refer to
references 1,2.
The recommendations include screening, diagnostic, and therapeutic actions that
are known or believed to favorably affect health outcomes of patients with
diabetes. Many of these interventions have also been shown to be cost-effective
(3). A grading system (Table 1) developed by ADA and modeled after existing
methods was used to clarify and codify the evidence that forms the basis for the
recommendations. The letters A, B, C, or E show the evidence level that supports
each recommendation. The Standards of Care conclude with evidence and
recommendations for strategies to improve the process of diabetes care. It must
be emphasized that clinical evidence and expert recommendations alone cannot
improve patients lives, but must be effectively translated into clinical
management.

I. CLASSIFICATION AND DIAGNOSIS


A. Classication
Diabetes can be classied into four clinical categories:

c Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin


deciency)
c Type 2 diabetes (due to a progressive insulin secretory defect on the background
of insulin resistance)
c Other specic types of diabetes due to other causes, e.g., genetic defects in b-cell
function, genetic defects in insulin action, diseases of the exocrine pancreas (such
as cystic brosis), and drug- or chemical-induced (such as in the treatment of HIV/
AIDS or after organ transplantation)
c Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that
is not clearly overt diabetes)

Some patients cannot be clearly classied as type 1 or type 2 diabetic.


Clinical presentation and disease progression vary considerably in both types of
diabetes. Occasionally, patients diagnosed with type 2 diabetes may present
Originally approved 1988. Most recent review/
with ketoacidosis. Children with type 1 diabetes typically present with the
revision October 2013.
hallmark symptoms of polyuria/polydipsia and occasionally with diabetic DOI: 10.2337/dc14-S014
ketoacidosis (DKA). However, difculties in diagnosis may occur in children, 2014 by the American Diabetes Association.
adolescents, and adults, with the true diagnosis becoming more obvious See http://creativecommons.org/licenses/by-
over time. nc-nd/3.0/ for details.
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care.diabetesjournals.org Position Statement S15

Table 1ADA evidence grading system for Clinical Practice Recommendations abnormal hemoglobins should be used.
Level of
An updated list is available at www.ngsp.
evidence Description org/interf.asp. In situations of abnormal
red cell turnover, such as pregnancy,
A Clear evidence from well-conducted, generalizable RCTs that are adequately
powered, including:
recent blood loss or transfusion, or some
c Evidence from a well-conducted multicenter trial anemias, only blood glucose criteria
c Evidence from a meta-analysis that incorporated quality ratings in the analysis should be used to diagnose diabetes.
Compelling nonexperimental evidence, i.e., all or none rule developed
by the Center for Evidence-Based Medicine at the University of Oxford Fasting and Two-Hour Plasma
Supportive evidence from well-conducted RCTs that are adequately powered, Glucose
including: In addition to the A1C test, the FPG and
c Evidence from a well-conducted trial at one or more institutions
2-h PG may also be used to diagnose
c Evidence from a meta-analysis that incorporated quality ratings in the analysis
diabetes. The current diagnostic criteria
B Supportive evidence from well-conducted cohort studies
c Evidence from a well-conducted prospective cohort study or registry
for diabetes are summarized in Table 2.
c Evidence from a well-conducted meta-analysis of cohort studies The concordance between the FPG and
Supportive evidence from a well-conducted case-control study 2-h PG tests is ,100%. The concordance
C Supportive evidence from poorly controlled or uncontrolled studies between A1C and either glucose-based
c Evidence from randomized clinical trials with one or more major or three test is also imperfect. National Health
or more minor methodological aws that could invalidate the results and Nutrition Examination Survey
c Evidence from observational studies with high potential for bias (such as case (NHANES) data indicate that the A1C cut
series with comparison with historical controls)
point of $6.5% identies one-third
c Evidence from case series or case reports
Conicting evidence with the weight of evidence supporting the recommendation
fewer cases of undiagnosed diabetes
E Expert consensus or clinical experience
than a fasting glucose cut point of
$126 mg/dL (7.0 mmol/L) (11).
Numerous studies have conrmed that,
B. Diagnosis of Diabetes cost, the limited availability of A1C at these cut points, the 2-h OGTT value
Diabetes is usually diagnosed based on testing in certain regions of the diagnoses more screened people with
plasma glucose criteria, either the developing world, and the incomplete diabetes (12). In reality, a large portion
fasting plasma glucose (FPG) or the 2-h correlation between A1C and average of the diabetic population remains
plasma glucose (2-h PG) value after a glucose in certain individuals. undiagnosed. Of note, the lower
75-g oral glucose tolerance test (OGTT) sensitivity of A1C at the designated cut
Race/Ethnicity point may be offset by the tests ability
(4). Recently, an International Expert
A1C levels may vary with patients race/ to facilitate the diagnosis.
Committee added the A1C (threshold
ethnicity (6,7). Glycation rates may differ
$6.5%) as a third option to diagnose
by race. For example, African Americans
diabetes (5) (Table 2).
may have higher rates of glycation, but this
Table 2Criteria for the diagnosis of
A1C is controversial. A recent epidemiological
diabetes
The A1C test should be performed study found that, when matched for FPG, A1C $6.5%. The test should be performed
using a method that is certied by the African Americans (with and without in a laboratory using a method that is
National Glycohemoglobin diabetes) had higher A1C than non- NGSP certied and standardized to the
Standardization Program (NGSP) and Hispanic whites, but also had higher levels DCCT assay.*
standardized or traceable to the of fructosamine and glycated albumin and OR
Diabetes Control and Complications lower levels of 1,5 anhydroglucitol, FPG $126 mg/dL (7.0 mmol/L). Fasting
Trial (DCCT) reference assay. Although suggesting that their glycemic burden is dened as no caloric intake for at
point-of-care (POC) A1C assays may be (particularly postprandially) may be least 8 h.*
NGSP-certied, prociency testing is not higher (8). Epidemiological studies OR
mandated for performing the test, so forming the framework for Two-hour PG $200 mg/dL (11.1 mmol/L)
use of these assays for diagnostic recommending A1C to diagnose diabetes during an OGTT. The test should be
performed as described by the WHO,
purposes may be problematic. have all been in adult populations. It is
using a glucose load containing the
Epidemiological data show a similar unclear if the same A1C cut point should equivalent of 75 g anhydrous glucose
relationship of A1C with the risk of be used to diagnose children or dissolved in water.*
retinopathy as seen with FPG and 2-h adolescents with diabetes (9,10). OR
PG. The A1C has several advantages to Anemias/Hemoglobinopathies In a patient with classic symptoms of
the FPG and OGTT, including greater Interpreting A1C levels in the presence of hyperglycemia or hyperglycemic crisis,
convenience (fasting not required), certain anemias and hemoglobinopathies a random plasma glucose $200 mg/dL
(11.1 mmol/L).
possibly greater preanalytical stability, is particularly problematic. For patients
and less day-to-day perturbations with an abnormal hemoglobin but normal *In the absence of unequivocal
during stress and illness. These red cell turnover, such as sickle cell trait, hyperglycemia, result should be conrmed
by repeat testing.
advantages must be balanced by greater an A1C assay without interference from
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S16 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

As with most diagnostic tests, a test It should be noted that the World Health follow-up should be pursued for those
result should be repeated when feasible Organization (WHO) and a number of considered at very high risk (e.g., those
to rule out laboratory error (e.g., an other diabetes organizations dene the with A1Cs .6.0%). Table 3 summarizes
elevated A1C should be repeated when cutoff for IFG at 110 mg/dL (6.1 mmol/L). the categories of prediabetes.
feasible, and not necessarily in 3 months). Prediabetes is the term used for
Unless there is a clear clinical diagnosis individuals with IFG and/or IGT, II. TESTING FOR DIABETES IN
(e.g., a patient in a hyperglycemic crisis or indicating the relatively high risk for the ASYMPTOMATIC PATIENTS
classic symptoms of hyperglycemia and a
future development of diabetes. IFG and Recommendations
random plasma glucose $200 mg/dL), it
IGT should not be viewed as clinical c Testing to detect type 2 diabetes and
is preferable that the same test be
entities in their own right but rather risk prediabetes in asymptomatic people
repeated for conrmation, since there
factors for diabetes and cardiovascular should be considered in adults of any
will be a greater likelihood of
disease (CVD). IFG and IGT are age who are overweight or obese
concurrence. For example, if the A1C is
7.0% and a repeat result is 6.8%, the
associated with obesity (especially (BMI $25 kg/m2) and who have one
abdominal or visceral obesity), or more additional risk factors for
diagnosis of diabetes is conrmed. If two
dyslipidemia with high triglycerides diabetes (Table 4). In those without
different tests (such as A1C and FPG) are
and/or low HDL cholesterol, and these risk factors, testing should
both above the diagnostic threshold, this
also conrms the diagnosis. hypertension. begin at age 45 years. B
c If tests are normal, repeat testing
On the other hand, if a patient has As with the glucose measures, several
prospective studies that used A1C to at least at 3-year intervals is
discordant results on two different reasonable. E
tests, then the test result that is above predict the progression to diabetes
c To test for diabetes or prediabetes,
the diagnostic cut point should be demonstrated a strong, continuous
association between A1C and the A1C, FPG, or 2-h 75-g OGTT are
repeated. The diagnosis is made on the appropriate. B
basis of the conrmed test. For subsequent diabetes. In a systematic
c In those identied with prediabetes,
example, if a patient meets the review of 44,203 individuals from 16
identify and, if appropriate, treat
diabetes criterion of the A1C (two cohort studies with a follow-up interval
other CVD risk factors. B
results $6.5%) but not the FPG averaging 5.6 years (range 2.812
(,126 mg/dL or 7.0 mmol/L), or vice years), those with an A1C between 5.5
and 6.0% had a substantially increased The same tests are used for both
versa, that person should be
risk of diabetes (5-year incidences from screening and diagnosing diabetes.
considered to have diabetes.
9 to 25%). An A1C range of 6.06.5% Diabetes may be identied anywhere
Since there is preanalytic and analytic along the spectrum of clinical scenarios:
had a 5-year risk of developing diabetes
variability of all the tests, it is possible from a seemingly low-risk individual
between 2550%, and a relative risk
that an abnormal result (i.e., above the who happens to have glucose testing,
(RR) 20 times higher compared with an
diagnostic threshold), when repeated, to a higher-risk individual whom the
A1C of 5.0% (15). In a community-based
will produce a value below the provider tests because of high suspicion
study of African American and non-
diagnostic cut point. This is least likely
Hispanic white adults without diabetes, of diabetes, and nally, to the
for A1C, somewhat more likely for FPG, symptomatic patient. The discussion
and most likely for the 2-h PG. Barring a baseline A1C was a stronger predictor of
herein is primarily framed as testing for
laboratory error, such patients will likely subsequent diabetes and
diabetes in asymptomatic individuals.
have test results near the margins of the cardiovascular events than fasting
The same assays used for testing will
diagnostic threshold. The health care glucose (16). Other analyses suggest
also detect individuals with
professional might opt to follow the that an A1C of 5.7% is associated with
prediabetes.
patient closely and repeat the test in similar diabetes risk to the high-risk
36 months. participants in the Diabetes Prevention
Program (DPP) (17).
C. Categories of Increased Risk for Table 3Categories of increased risk
Diabetes (Prediabetes) Hence, it is reasonable to consider an
for diabetes (prediabetes)*
In 1997 and 2003, the Expert Committee A1C range of 5.76.4% as identifying FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL
on Diagnosis and Classication of individuals with prediabetes. As with (6.9 mmol/L) (IFG)
Diabetes Mellitus (13,14) recognized a those with IFG and IGT, individuals with OR
group of individuals whose glucose an A1C of 5.76.4% should be informed 2-h PG in the 75-g OGTT 140 mg/dL
levels did not meet the criteria for of their increased risk for diabetes and (7.8 mmol/L) to 199 mg/dL
diabetes, but were too high to be CVD and counseled about effective (11.0 mmol/L) (IGT)
considered normal. These persons were strategies to lower their risks (see OR
dened as having impaired fasting Section IV). Similar to glucose A1C 5.76.4%
glucose (IFG) (FPG levels 100125 mg/dL measurements, the continuum of risk is *For all three tests, risk is continuous,
[5.66.9 mmol/L]), or impaired glucose curvilinear, so as A1C rises, the diabetes extending below the lower limit of the range
tolerance (IGT) (2-h PG OGTT values of risk rises disproportionately (15). and becoming disproportionately greater at
higher ends of the range.
140199 mg/dL [7.811.0 mmol/L]). Aggressive interventions and vigilant
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care.diabetesjournals.org Position Statement S17

Table 4Criteria for testing for diabetes in asymptomatic adult individuals in Chinese, and 26 kg/m2 in African
1. Testing should be considered in all adults who are overweight (BMI $25 kg/m2*) and have Americans (21). Disparities in screening
additional risk factors: rates, not explainable by insurance
c physical inactivity status, are highlighted by evidence that
c rst-degree relative with diabetes despite much higher prevalence of type 2
c high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
diabetes, ethnic minorities in an insured
American, Pacic Islander)
c women who delivered a baby weighing .9 lb or were diagnosed with GDM
population are no more likely than non-
c hypertension ($140/90 mmHg or on therapy for hypertension) Hispanic whites to be screened for
c HDL cholesterol level ,35 mg/dL (0.90 mmol/L) and/or a triglyceride level diabetes (22). Because age is a major risk
.250 mg/dL (2.82 mmol/L) factor for diabetes, in those without these
c women with polycystic ovarian syndrome risk factors, testing should begin at age
c A1C $5.7%, IGT, or IFG on previous testing 45 years.
c other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans) The A1C, FPG, or the 2-h OGTT are
c history of CVD appropriate for testing. It should be
2. In the absence of the above criteria, testing for diabetes should begin at age 45 years. noted that the tests do not necessarily
3. If results are normal, testing should be repeated at least at 3-year intervals, with detect diabetes in the same individuals.
consideration of more frequent testing depending on initial results (e.g., those with The efcacy of interventions for primary
prediabetes should be tested yearly) and risk status. prevention of type 2 diabetes (2329)
*At-risk BMI may be lower in some ethnic groups. has primarily been demonstrated
among individuals with IGT, not for
individuals with isolated IFG or for
A. Testing for Type 2 Diabetes and with intensive treatment. Incidence of individuals with specic A1C levels.
Risk of Future Diabetes in Adults rst CVD event and mortality rates were
Testing Interval
Prediabetes and diabetes meet not signicantly different between
The appropriate interval between tests
established criteria for conditions in groups (18). This study would seem to
is not known (30). The rationale for the
which early detection is appropriate. add support for early treatment of
3-year interval is that false negatives will
Both conditions are common, are screen-detected diabetes, as risk factor
be repeated before substantial time
increasing in prevalence, and impose control was excellent even in the
elapses. It is also unlikely that an
signicant public health burdens. There routine treatment arm and both groups
individual will develop signicant
is often a long presymptomatic phase had lower event rates than predicted.
complications of diabetes within 3 years
before the diagnosis of type 2 diabetes The absence of a control unscreened
of a negative test result. In the modeling
is made. Simple tests to detect arm limits the ability to denitely prove
study, repeat screening every 3 or 5 years
preclinical disease are readily available. that screening impacts outcomes.
was cost-effective (19).
The duration of glycemic burden is a Mathematical modeling studies
strong predictor of adverse outcomes, suggest that screening, independent of Community Screening
and effective interventions exist to risk factors, beginning at age 30 or Testing should be carried out within the
prevent progression of prediabetes to 45 years is highly cost-effective health care setting because of the need
diabetes (see Section IV) and to reduce (,$11,000 per quality-adjusted life- for follow-up and discussion of
risk of complications of diabetes (see year gained) (19). abnormal results. Community screening
Section VI). outside a health care setting is not
BMI Cut Points recommended because people with
Type 2 diabetes is frequently not Testing recommendations for diabetes positive tests may not seek, or have
diagnosed until complications appear. in asymptomatic, undiagnosed adults access to, appropriate follow-up testing
Approximately one-fourth of the U.S. are listed in Table 4. Testing should be and care. Conversely, there may be
population may have undiagnosed considered in adults of any age with BMI failure to ensure appropriate repeat
diabetes. Mass screening of $25 kg/m2 and one or more of the testing for individuals who test
asymptomatic individuals has not known risk factors for diabetes. In negative. Community screening may
effectively identied those with addition to the listed risk factors, certain also be poorly targeted; i.e., it may fail to
prediabetes or diabetes, and rigorous medications, such as glucocorticoids reach the groups most at risk and
clinical trials to provide such proof are and antipsychotics (20), are known to inappropriately test those at low risk or
unlikely to occur. In a large randomized increase the risk of type 2 diabetes. even those already diagnosed.
controlled trial (RCT) in Europe, general There is compelling evidence that lower
practice patients between the ages of BMI cut points suggest diabetes risk in B. Screening for Type 2 Diabetes in
4069 years were screened for diabetes, some racial and ethnic groups. In a large Children
then randomized by practice to routine multiethnic cohort study, for an Recommendation
diabetes care or intensive treatment of equivalent incidence rate of diabetes c Testing to detect type 2 diabetes and
multiple risk factors. After 5.3 years of conferred by a BMI of 30 kg/m2 in non- prediabetes should be considered in
follow-up, CVD risk factors were Hispanic whites, the BMI cutoff value children and adolescents who are
modestly but signicantly improved was 24 kg/m2 in South Asians, 25 kg/m2 overweight and who have two or
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S18 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

more additional risk factors for C. Screening for Type 1 Diabetes Individuals who screen positive will be
diabetes (Table 5). E Recommendation counseled about the risk of
c Inform type 1 diabetic patients of the developing diabetes, diabetes
In the last decade, the incidence of type 2 opportunity to have their relatives symptoms, and the prevention of DKA.
diabetes in adolescents has increased screened for type 1 diabetes risk in the Numerous clinical studies are being
dramatically, especially in minority setting of a clinical research study. E conducted to test various methods of
populations (31). As with adult preventing type 1 diabetes in those
recommendations, children and youth at with evidence of autoimmunity (www
increased risk for the presence or the Type 1 diabetic patients often present
.clinicaltrials.gov).
development of type 2 diabetes should be with acute symptoms of diabetes and
tested within the health care setting (32). markedly elevated blood glucose levels, III. DETECTION AND DIAGNOSIS OF
and some cases are diagnosed with life- GESTATIONAL DIABETES MELLITUS
A1C in Pediatrics threatening ketoacidosis. The incidence Recommendations
Recent studies question the validity of and prevalence of type 1 diabetes is
c Screen for undiagnosed type 2
A1C in the pediatric population, increasing (31,37,38). Several studies
diabetes at the rst prenatal visit in
especially in ethnic minorities, and suggest that measuring islet
those with risk factors, using standard
suggest OGTT or FPG as more suitable autoantibodies in relatives of those with
diagnostic criteria. B
diagnostic tests (33). However, many of type 1 diabetes may identify individuals
c Screen for GDM at 2428 weeks of
these studies do not recognize that who are at risk for developing type 1
gestation in pregnant women not
diabetes diagnostic criteria are based diabetes. Such testing, coupled with
previously known to have diabetes. A
upon long-term health outcomes, and education about diabetes symptoms
c Screen women with GDM for
validations are not currently available in and close follow-up in an observational
persistent diabetes at 612 weeks
the pediatric population (34). ADA clinical study, may enable earlier
postpartum, using the OGTT and
acknowledges the limited data identication of type 1 diabetes onset.
nonpregnancy diagnostic criteria. E
supporting A1C for diagnosing diabetes A recent study reported the risk of
c Women with a history of GDM should
in children and adolescents. However, progression to type 1 diabetes from the
have lifelong screening for the
aside from rare instances, such as cystic time of seroconversion to autoantibody
development of diabetes or
brosis and hemoglobinopathies, positivity in three pediatric cohorts from
prediabetes at least every 3 years. B
ADA continues to recommend A1C in Finland, Germany, and the U.S. Of the
c Women with a history of GDM found
this cohort (35,36). The modied 585 children who developed more than
to have prediabetes should receive
recommendations of the ADA two autoantibodies, nearly 70%
lifestyle interventions or metformin
consensus statement Type 2 Diabetes developed type 1 diabetes within 10
to prevent diabetes. A
in Children and Adolescents are years and 84% within 15 years (39,40).
c Further research is needed to
summarized in Table 5. These ndings are highly signicant
establish a uniform approach to
because, while the German group was
diagnosing GDM. E
Table 5Testing for type 2 diabetes recruited from offspring of parents with
in asymptomatic children* type 1 diabetes, the Finnish and For many years, GDM was dened as
Criteria Colorado groups were recruited from any degree of glucose intolerance with
c Overweight (BMI .85th percentile for the general population. Remarkably, the
age and sex, weight for height .85th onset or rst recognition during
ndings in all three groups were the pregnancy (13), whether or not the
percentile, or weight .120% of ideal
same, suggesting that the same condition persisted after pregnancy,
for height)
sequence of events led to clinical and not excluding the possibility that
Plus any two of the following risk factors:
c Family history of type 2 diabetes in
disease in both sporadic and genetic unrecognized glucose intolerance may
rst- or second-degree relative cases of type 1 diabetes. There is have antedated or begun concomitantly
c Race/ethnicity (Native American, evidence to suggest that early diagnosis with the pregnancy. This denition
African American, Latino, Asian may limit acute complications (39) and facilitated a uniform strategy for
American, Pacic Islander) extend long-term endogenous insulin
c Signs of insulin resistance or
detection and classication of GDM, but
production (41). While there is its limitations were recognized for many
conditions associated with insulin
resistance (acanthosis nigricans,
currently a lack of accepted screening years. As the ongoing epidemic of
hypertension, dyslipidemia, programs, one should consider referring obesity and diabetes has led to more
polycystic ovarian syndrome, or relatives of those with type 1 diabetes type 2 diabetes in women of
small-for-gestational-age birth weight) for antibody testing for risk assessment childbearing age, the number of
c Maternal history of diabetes or GDM in the setting of a clinical research study
during the childs gestation
pregnant women with undiagnosed
(http://www2.diabetestrialnet.org). type 2 diabetes has increased (42).
Age of initiation: age 10 years or at onset
of puberty, if puberty occurs at Widespread clinical testing of Because of this, it is reasonable to
a younger age asymptomatic low-risk individuals is not screen women with risk factors for type
Frequency: every 3 years currently recommended. Higher-risk 2 diabetes (Table 4) at their initial
individuals may be screened, but only in prenatal visit, using standard diagnostic
*Persons aged 18 years and younger.
the context of a clinical research setting. criteria (Table 2). Women with diabetes
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care.diabetesjournals.org Position Statement S19

in the rst trimester should receive a Table 6Screening for and diagnosis hyperglycemia impacts prognosis of
diagnosis of overt, not gestational, of GDM future diabetes for the mother and
diabetes. One-step (IADPSG consensus) future obesity, diabetes risk, or other
GDM carries risks for the mother and
Perform a 75-g OGTT, with plasma glucose metabolic consequences for the
measurement fasting and at 1 and 2 h, offspring. The frequency of follow-up
neonate. Not all adverse outcomes are at 2428 weeks of gestation in women
of equal clinical importance. The and blood glucose monitoring for these
not previously diagnosed with overt
Hyperglycemia and Adverse Pregnancy diabetes.
women has also not yet been
Outcome (HAPO) study (43), a large- The OGTT should be performed in the standardized, but is likely to be less
scale (;25,000 pregnant women) morning after an overnight fast of at intensive than for women diagnosed by
least 8 h. the older criteria.
multinational epidemiological study,
The diagnosis of GDM is made when any of
demonstrated that risk of adverse the following plasma glucose values are National Institutes of Health
maternal, fetal, and neonatal exceeded: Consensus Report
outcomes continuously increased as a c Fasting: $92 mg/dL (5.1 mmol/L) Since this initial IADPSG
function of maternal glycemia at 2428 c 1 h: $180 mg/dL (10.0 mmol/L)
recommendation, the National
weeks, even within ranges previously c 2 h: $153 mg/dL (8.5 mmol/L)
Institutes of Health (NIH) completed a
considered normal for pregnancy. For Two-step (NIH consensus)
consensus development conference
Perform a 50-g GLT (nonfasting), with
most complications, there was no involving a 15-member panel with
plasma glucose measurement at 1 h
threshold for risk. These results have (Step 1), at 2428 weeks of gestation in representatives from obstetrics/
led to careful reconsideration of the women not previously diagnosed with gynecology, maternal-fetal medicine,
diagnostic criteria for GDM. GDM overt diabetes. pediatrics, diabetes research,
screening can be accomplished with If the plasma glucose level measured 1 h biostatistics, and other related elds
either of two strategies: after the load is $140 mg/dL* (10.0 (48). Reviewing the same available data,
mmol/L), proceed to 100-g OGTT (Step 2).
the NIH consensus panel recommended
The 100-g OGTT should be performed
1. One-step 2-h 75-g OGTT or continuation of the two-step
when the patient is fasting.
2. Two-step approach with a 1-h The diagnosis of GDM is made when the approach of screening with a 1-h 50-g
50-g (nonfasting) screen followed plasma glucose level measured 3 h after glucose load test (GLT) followed by a 3-h
by a 3-h 100-g OGTT for those who the test is $140 mg/dL (7.8 mmol/L). 100-g OGTT for those who screen
screen positive (Table 6) *The American College of Obstetricians and positive, a strategy commonly used in
Gynecologists (ACOG) recommends a lower the U.S. Key factors reported in the NIH
Different diagnostic criteria will identify threshold of 135 mg/dL in high-risk ethnic panels decision-making process were
different magnitudes of maternal minorities with higher prevalence of GDM.
the lack of clinical trial interventions
hyperglycemia and maternal/fetal risk. demonstrating the benets of the one-
In the 2011 Standards of Care (44), ADA step strategy and the potential
for the rst time recommended that all recommended these diagnostic criteria negative consequences of identifying a
pregnant women not known to have changes in the context of worrisome large new group of women with GDM.
prior diabetes undergo a 75-g OGTT at worldwide increases in obesity and Moreover, screening with a 50-g GLT
2428 weeks of gestation based on an diabetes rates with the intent of does not require fasting and is
International Association of Diabetes optimizing gestational outcomes for therefore easier to accomplish for
and Pregnancy Study Groups (IADPSG) women and their babies. It is important many women. Treatment of higher
consensus meeting (45). Diagnostic cut to note that 8090% of women in both threshold maternal hyperglycemia, as
points for the fasting, 1-h, and 2-h PG of the mild GDM studies (whose glucose identied by the two-step approach,
measurements were dened that values overlapped with the thresholds reduces rates of neonatal macrosomia,
conveyed an odds ratio for adverse recommended herein) could be LGA, and shoulder dystocia, without
outcomes of at least 1.75 compared managed with lifestyle therapy alone. increasing small-for-gestational-age
with women with the mean glucose The expected benets to these births (49).
levels in the HAPO study, a strategy pregnancies and offspring are inferred How do two different groups of experts
anticipated to signicantly increase the from intervention trials that focused on arrive at different GDM screening and
prevalence of GDM (from 56% to women with lower levels of diagnosis recommendations? Because
;1520%), primarily because only one hyperglycemia than identied using glycemic dysregulation exists on a
abnormal value, not two, is sufcient to older GDM diagnostic criteria and that continuum, the decision to pick a single
make the diagnosis. ADA recognized found modest benets including binary threshold for diagnosis requires
that the anticipated increase in the reduced rates of large-for-gestational- balancing the harms and benets
incidence of GDM diagnosed by these age (LGA) births (46,47). However, while associated with greater versus lesser
criteria would have signicant impact on treatment of lower threshold sensitivity. While data from the HAPO
the costs, medical infrastructure hyperglycemia can reduce LGA, it has study demonstrated a correlation
capacity, and potential for increased not been shown to reduce primary between increased fasting glucose
medicalization of pregnancies cesarean delivery rates. Data are lacking levels identied through the one-step
previously categorized as normal, but on how treatment of lower threshold strategy with increased odds for adverse
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S20 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

pregnancy outcomes, this large patterns. Adjusting for BMI moderately, in the DPP are cost-effective (56), and
observational study was not designed but not completely, attenuated this actual cost data from the DPP and
to determine the benet of association (52). DPPOS conrm that lifestyle
intervention. Moreover, there are no interventions are highly cost-effective
IV. PREVENTION/DELAY OF TYPE 2
available cost-effective analyses to (57). Group delivery of the DPP
DIABETES
examine the balance of achieved intervention in community settings has
benets versus the increased costs Recommendations the potential to be signicantly less
generated by this strategy. c Patients with IGT A, IFG E, or an A1C expensive while still achieving similar
The conicting recommendations from 5.76.4% E should be referred to an weight loss (58). The Centers for Disease
these two consensus panels underscore effective ongoing support program Control and Prevention (CDC) helps
several key points: targeting weight loss of 7% of body coordinate the National Diabetes
weight and increasing physical Prevention Program, a resource designed
1. There are insufcient data to activity to at least 150 min/week of to bring evidence-based lifestyle change
strongly demonstrate the superiority moderate activity such as walking. programs for preventing type 2 diabetes
c Follow-up counseling appears to be to communities (http://www.cdc.gov/
of one strategy over the other.
2. The decision of which strategy to important for success. B diabetes/prevention/index.htm).
c Based on the cost-effectiveness of
implement must therefore be made Given the clinical trial results and the
based on the relative values placed diabetes prevention, such programs
known risks of progression of
on currently unmeasured factors should be covered by third-party
prediabetes to diabetes, persons with
(e.g., cost-benet estimation, payers. B
an A1C of 5.76.4%, IGT, or IFG should
c Metformin therapy for prevention of
willingness to change practice based be counseled on lifestyle changes with
on correlation studies rather than type 2 diabetes may be considered
goals similar to those of the DPP (7%
clinical intervention trial results, in those with IGT A, IFG E, or an
weight loss and moderate physical
relative role of cost considerations, A1C 5.76.4% E, especially for those
activity of at least 150 min/week).
and available infrastructure). with BMI .35 kg/m2, aged
Metformin has a strong evidence base
3. Further research is needed to resolve ,60 years, and women with prior
GDM. A and demonstrated long-term safety as
these uncertainties. pharmacological therapy for diabetes
c At least annual monitoring for the
development of diabetes in those prevention (59). For other drugs, cost,
There remains strong consensus that side effects, and lack of a persistent
establishing a uniform approach to with prediabetes is suggested. E
c Screening for and treatment of effect require consideration (60).
diagnosing GDM will have extensive
benets for patients, caregivers, and modiable risk factors for CVD is
Metformin
policymakers. Longer-term outcome suggested. B
Metformin was less effective than
studies are currently underway. lifestyle modication in the DPP and
RCTs have shown that individuals at high
Because some cases of GDM may DPPOS, but may be cost-saving over a
risk for developing type 2 diabetes (IFG,
represent preexisting undiagnosed type 10-year period (57). It was as effective as
IGT, or both) can signicantly decrease
2 diabetes, women with a history of lifestyle modication in participants
the rate of diabetes onset with
GDM should be screened for diabetes with a BMI $35 kg/m2, but not
particular interventions (2329). These
612 weeks postpartum, using signicantly better than placebo in
include intensive lifestyle modication
nonpregnant OGTT criteria. Because of those over age 60 years (23). In the DPP,
programs that have been shown to be
their antepartum treatment for for women with a history of GDM,
very effective (;58% reduction after
hyperglycemia, A1C for diagnosis of metformin and intensive lifestyle
3 years) and pharmacological agents
modication led to an equivalent 50%
persistent diabetes at the postpartum metformin, a-glucosidase inhibitors,
visit is not recommended (50). Women reduction in diabetes risk (61).
orlistat, and thiazolidinediones, each of
with a history of GDM have a greatly Metformin therefore might reasonably
which has been shown to decrease
increased subsequent diabetes risk (51) be recommended for very-high-risk
incident diabetes to various degrees.
and should be followed up with individuals (e.g., history of GDM, very
Follow-up of all three large studies of
subsequent screening for the obese, and/or those with more severe
lifestyle intervention has shown
development of diabetes or or progressive hyperglycemia).
sustained reduction in the rate of
prediabetes, as outlined in Section II. conversion to type 2 diabetes, with 43% People with prediabetes often have
Lifestyle interventions or metformin reduction at 20 years in the Da Qing other cardiovascular risk factors, such as
should be offered to women with a study (53), 43% reduction at 7 years in obesity, hypertension, and
history of GDM who develop the Finnish Diabetes Prevention Study dyslipidemia, and are at increased risk
prediabetes, as discussed in Section IV. (DPS) (54), and 34% reduction at 10 for CVD events. While treatment goals
In the prospective Nurses Health Study years in the U.S. Diabetes Prevention are the same as for other patients
II, subsequent diabetes risk after a Program Outcomes Study (DPPOS) (55). without diabetes, increased vigilance is
history of GDM was signicantly lower A cost-effectiveness model suggested warranted to identify and treat these
in women who followed healthy eating that lifestyle interventions as delivered and other risk factors (e.g., smoking).
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care.diabetesjournals.org Position Statement S21

V. DIABETES CARE enable the health care team to The management plan should be
A. Initial Evaluation optimally manage the patient with formulated as a collaborative
A complete medical evaluation should diabetes. therapeutic alliance among the patient
be performed to classify the diabetes, and family, the physician, and other
detect the presence of diabetes B. Management members of the health care team. A
complications, review previous People with diabetes should receive variety of strategies and techniques
treatment and risk factor control in medical care from a team that may should be used to provide adequate
patients with established diabetes, include physicians, nurse practitioners, education and development of
assist in formulating a management physicians assistants, nurses, dietitians, problem-solving skills in the numerous
plan, and provide a basis for continuing pharmacists, and mental health aspects of diabetes management.
care. Laboratory tests appropriate to professionals with expertise in diabetes. Treatment goals and plans should be
the evaluation of each patients In this collaborative and integrated individualized and take patient
medical condition should be team approach, the individuals with preferences into account. The
completed. A focus on the components diabetes must also assume an active management plan should recognize
of comprehensive care (Table 7) will role in their care. diabetes self-management education
(DSME) and ongoing diabetes support as
integral components of care. In
developing the plan, consideration
Table 7Components of the comprehensive diabetes evaluation
Medical history should be given to the patients age,
c Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory nding) school or work schedule and conditions,
c Eating patterns, physical activity habits, nutritional status, and weight history; growth and physical activity, eating patterns, social
development in children and adolescents situation and cultural factors, presence
c Diabetes education history of diabetes complications, health
c Review of previous treatment regimens and response to therapy (A1C records)
priorities, and other medical conditions.
c Current treatment of diabetes, including medications, medication adherence and barriers
thereto, meal plan, physical activity patterns, and readiness for behavior change C. Glycemic Control
c Results of glucose monitoring and patients use of data
1. Assessment of Glycemic Control
c DKA frequency, severity, and cause
Two primary techniques are available
c Hypoglycemic episodes
c Hypoglycemia awareness
for health providers and patients to
c Any severe hypoglycemia: frequency and cause assess the effectiveness of the
c History of diabetes-related complications management plan on glycemic control:
c Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of patient self-monitoring of blood glucose
foot lesions; autonomic, including sexual dysfunction and gastroparesis) (SMBG) or interstitial glucose, and A1C.
c Macrovascular: CHD, cerebrovascular disease, and PAD
c Other: psychosocial problems,* dental disease* a. Glucose Monitoring
Physical examination Recommendations
c Height, weight, BMI c Patients on multiple-dose insulin
c Blood pressure determination, including orthostatic measurements when indicated (MDI) or insulin pump therapy should
c Fundoscopic examination* do SMBG prior to meals and snacks,
c Thyroid palpation
occasionally postprandially, at
c Skin examination (for acanthosis nigricans and insulin injection sites)
c Comprehensive foot examination
bedtime, prior to exercise, when they
c Inspection suspect low blood glucose, after
c Palpation of dorsalis pedis and posterior tibial pulses treating low blood glucose until they
c Presence/absence of patellar and Achilles reexes are normoglycemic, and prior to
c Determination of proprioception, vibration, and monolament sensation critical tasks such as driving. B
Laboratory evaluation c When prescribed as part of a broader
c A1C, if results not available within past 23 months educational context, SMBG results
c If not performed/available within past year
may be helpful to guide treatment
c Fasting lipid prole, including total, LDL, and HDL cholesterol and triglycerides
c Liver function tests
decisions and/or patient self-
c Test for urine albumin excretion with spot urine albumin-to-creatinine ratio management for patients using less
c Serum creatinine and calculated GFR frequent insulin injections or
c TSH in type 1 diabetes, dyslipidemia, or women over age 50 years noninsulin therapies. E
Referrals c When prescribing SMBG, ensure that
c Eye care professional for annual dilated eye exam patients receive ongoing instruction
c Family planning for women of reproductive age and regular evaluation of SMBG
c Registered dietitian for MNT
technique and SMBG results, as well
c DSME
c Dentist for comprehensive periodontal examination
as their ability to use SMBG data to
c Mental health professional, if needed adjust therapy. E
c When used properly, continuous
*See appropriate referrals for these categories.
glucose monitoring (CGM) in
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S22 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

conjunction with intensive insulin complications (63). For patients on of 322 type 1 diabetic patients showed
regimens is a useful tool to lower A1C nonintensive insulin regimens, such as that adults aged $25 years using
in selected adults (aged $25 years) those with type 2 diabetes on basal intensive insulin therapy and CGM
with type 1 diabetes. A insulin, when to prescribe SMBG and the experienced a 0.5% reduction in A1C
c Although the evidence for A1C testing frequency are unclear because (from ;7.6 to 7.1%) compared with usual
lowering is less strong in children, there is insufcient evidence for testing intensive insulin therapy with SMBG (72).
teens, and younger adults, CGM may in this cohort. Sensor use in those ,25 years of age
be helpful in these groups. Success Several randomized trials have called (children, teens, and adults) did not result
correlates with adherence to ongoing into question the clinical utility and cost- in signicant A1C lowering, and there was
use of the device. C effectiveness of routine SMBG in no signicant difference in hypoglycemia
c CGM may be a supplemental tool to in any group. The greatest predictor of
noninsulin-treated patients (6466).
SMBG in those with hypoglycemia A1C lowering for all age-groups was
A recent meta-analysis suggested that
unawareness and/or frequent frequency of sensor use, which was lower
SMBG reduced A1C by 0.25% at
hypoglycemic episodes. E in younger age-groups. In a smaller RCT of
6 months (67), but a Cochrane review
129 adults and children with baseline A1C
Major clinical trials of insulin-treated concluded that the overall effect of
,7.0%, outcomes combining A1C and
patients that demonstrated the benets SMBG in such patients is minimal up to
hypoglycemia favored the group using
of intensive glycemic control on 6 months after initiation and subsides
CGM, suggesting that CGM is also
diabetes complications have included after 12 months (68). A key
benecial for individuals with type 1
SMBG as part of multifactorial consideration is that SMBG alone does
diabetes who have already achieved
interventions, suggesting that SMBG is a not lower blood glucose level; to be
excellent control (72).
component of effective therapy. SMBG useful, the information must be
allows patients to evaluate their integrated into clinical and self- Overall, meta-analyses suggest that
individual response to therapy and management plans. compared with SMBG, CGM use is
assess whether glycemic targets are associated with A1C lowering by
SMBG accuracy is instrument and user
being achieved. Results of SMBG can be ;0.26% (73). The technology may be
dependent (69), so it is important to
useful in preventing hypoglycemia and particularly useful in those with
evaluate each patients monitoring
adjusting medications (particularly hypoglycemia unawareness and/or
technique, both initially and at regular
prandial insulin doses), medical frequent hypoglycemic episodes,
intervals thereafter. Optimal use of
nutrition therapy (MNT), and physical although studies have not shown
SMBG requires proper review and
activity. Evidence also supports a signicant reductions in severe
interpretation of the data, both by the
correlation between SMBG frequency hypoglycemia (73). A CGM device
patient and provider. Among patients
and lower A1C (62). equipped with an automatic low glucose
who checked their blood glucose at least
suspend feature was recently approved
SMBG frequency and timing should be once daily, many reported taking no by the U.S. Food and Drug
dictated by the patients specic needs action when results were high or low Administration (FDA). The ASPIRE trial
and goals. SMBG is especially important (70). In one study of insulin-nave of 247 patients showed that sensor-
for patients treated with insulin to patients with suboptimal initial glycemic augmented insulin pump therapy with a
monitor for and prevent asymptomatic control, use of structured SMBG (a low glucose suspend signicantly
hypoglycemia and hyperglycemia. Most paper tool to collect and interpret reduced nocturnal hypoglycemia,
patients with type 1 diabetes or on 7-point SMBG proles over 3 days at without increasing A1C levels for those
intensive insulin regimens (MDI or least quarterly) reduced A1C by 0.3% over 16 years of age (74). These devices
insulin pump therapy) should consider more than an active control group (71). may offer the opportunity to reduce
SMBG prior to meals and snacks, Patients should be taught how to use severe hypoglycemia for those with a
occasionally postprandially, at bedtime, SMBG data to adjust food intake, history of nocturnal hypoglycemia. CGM
prior to exercise, when they suspect low exercise, or pharmacological therapy to forms the underpinning for the articial
blood glucose, after treating low blood achieve specic goals. The ongoing need pancreas or the closed-loop system.
glucose until they are normoglycemic, for and frequency of SMBG should be However, before CGM is widely adopted,
and prior to critical tasks such as driving. reevaluated at each routine visit. data must be reported and analyzed
For many patients, this will require using a standard universal template that
testing 68 times daily, although Continuous Glucose Monitoring is predictable and intuitive (75).
individual needs may vary. A database Real-time CGM through the
study of almost 27,000 children and measurement of interstitial glucose b. A1C
adolescents with type 1 diabetes (which correlates well with plasma Recommendations
showed that, after adjustment for glucose) is available. These sensors c Perform the A1C test at least two
multiple confounders, increased daily require calibration with SMBG, and the times a year in patients who are
frequency of SMBG was signicantly latter are still required for making acute meeting treatment goals (and who
associated with lower A1C (20.2% per treatment decisions. CGM devices have have stable glycemic control). E
additional test per day, leveling off at alarms for hypo- and hyperglycemic c Perform the A1C test quarterly in
ve tests per day) and with fewer acute excursions. A 26-week randomized trial patients whose therapy has changed
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care.diabetesjournals.org Position Statement S23

or who are not meeting glycemic Table 8Correlation of A1C with to different interpretations of the clinical
goals. E average glucose meaning of given levels of A1C in those
c Use of POC testing for A1C provides Mean plasma glucose populations.
the opportunity for more timely For patients in whom A1C/eAG and
A1C (%) mg/dL mmol/L
treatment changes. E measured blood glucose appear
6 126 7.0
discrepant, clinicians should consider the
A1C reects average glycemia over 7 154 8.6
possibilities of hemoglobinopathy or
several months (69) and has strong 8 183 10.2
altered red cell turnover, and the options of
predictive value for diabetes 9 212 11.8
more frequent and/or different timing
complications (76,77). Thus, A1C testing 10 240 13.4
of SMBG or use of CGM. Other measures
should be performed routinely in all 11 269 14.9
of chronic glycemia such as fructosamine
patients with diabetes: at initial 12 298 16.5
are available, but their linkage to
assessment and as part of continuing These estimates are based on ADAG data of average glucose and their prognostic
care. Measurement approximately ;2,700 glucose measurements over 3 signicance are not as clear as for A1C.
every 3 months determines whether a months per A1C measurement in 507 adults
with type 1, type 2, and no diabetes. The 2. Glycemic Goals in Adults
patients glycemic targets have been
correlation between A1C and average Recommendations
reached and maintained. The frequency glucose was 0.92 (ref. 78). A calculator for
of A1C testing should be dependent on converting A1C results into eAG, in either c Lowering A1C to below or around 7%
the clinical situation, the treatment mg/dL or mmol/L, is available at http:// has been shown to reduce
professional.diabetes.org/eAG. microvascular complications of
regimen used, and the clinicians
judgment. Some patients with stable diabetes and, if implemented soon
glycemia well within target may do well after the diagnosis of diabetes, is
with testing only twice per year. Chemistry have determined that the associated with long-term reduction
Unstable or highly intensively managed correlation (r 5 0.92) is strong enough to in macrovascular disease.
patients (e.g., pregnant type 1 diabetic justify reporting both the A1C result and Therefore, a reasonable A1C goal for
women) may require testing more an estimated average glucose (eAG) many nonpregnant adults is ,7%. B
frequently than every 3 months. result when a clinician orders the A1C c Providers might reasonably suggest
test. The table in pre-2009 versions of the more stringent A1C goals (such as
A1C Limitations Standards of Medical Care in Diabetes ,6.5%) for selected individual
As mentioned above, the A1C test is describing the correlation between A1C patients, if this can be achieved
subject to certain limitations. and mean glucose was derived from without signicant hypoglycemia or
Conditions that affect erythrocyte relatively sparse data (one 7-point prole other adverse effects of treatment.
turnover (hemolysis, blood loss) and over 1 day per A1C reading) in the Appropriate patients might include
hemoglobin variants must be primarily non-Hispanic white type 1 those with short duration of diabetes,
considered, particularly when the A1C diabetic participants in the DCCT (79). long life expectancy, and no
result does not correlate with the Clinicians should note that the numbers signicant CVD. C
patients clinical situation (69). A1C also in the table are now different because c Less stringent A1C goals (such as ,8%)
does not provide a measure of glycemic they are based on ;2,800 readings per may be appropriate for patients with a
variability or hypoglycemia. For patients A1C in the ADAG trial. history of severe hypoglycemia, limited
prone to glycemic variability, especially life expectancy, advanced
In the ADAG study, there were no
type 1 diabetic patients or type 2 microvascular or macrovascular
signicant differences among racial and
diabetic patients with severe insulin complications, and extensive comorbid
ethnic groups in the regression lines
deciency, glycemic control is best conditions and in those with long-
between A1C and mean glucose,
evaluated by the combination of results standing diabetes in whom the general
although there was a trend toward a
from self-monitoring and the A1C. The goal is difcult to attain despite DSME,
difference between the African/African
A1C may also conrm the accuracy of appropriate glucose monitoring, and
American and non-Hispanic white
the patients meter (or the patients effective doses of multiple glucose-
cohorts. A small study comparing A1C to
reported SMBG results) and the lowering agents including insulin. B
CGM data in type 1 diabetic children
adequacy of the SMBG testing schedule.
found a highly statistically signicant Diabetes Control and Complications
A1C and Plasma Glucose correlation between A1C and mean blood Trial/Epidemiology of Diabetes
Table 8 contains the correlation glucose, although the correlation (r 5 Interventions and Complications
between A1C levels and mean plasma 0.7) was signicantly lower than in the Hyperglycemia denes diabetes, and
glucose levels based on data from the ADAG trial (80). Whether there are glycemic control is fundamental to
international A1C-Derived Average signicant differences in how A1C relates diabetes management. The DCCT study
Glucose (ADAG) trial using frequent to average glucose in children or in (76), a prospective RCT of intensive
SMBG and CGM in 507 adults (83% non- African American patients is an area for versus standard glycemic control in
Hispanic whites) with type 1, type 2, further study (33,81). For the time being, patients with relatively recently
and no diabetes (78). The ADA and the the question has not led to different diagnosed type 1 diabetes showed
American Association for Clinical recommendations about testing A1C or denitively that improved glycemic
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S24 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

control is associated with signicantly when setting glycemic targets. either known CVD or multiple
decreased rates of microvascular However, based on physician judgment cardiovascular risk factors. Details of
(retinopathy and nephropathy) and and patient preferences, select patients, these studies are reviewed extensively in
neuropathic complications. Follow-up especially those with little comorbidity an ADA position statement (94).
of the DCCT cohorts in the Epidemiology and long life expectancy, may benet
ACCORD
of Diabetes Interventions and from adopting more intensive glycemic
The ACCORD study participants had
Complications (EDIC) study (82,83) targets (e.g., A1C target ,6.5%) as long
either known CVD or two or more major
demonstrated persistence of these as signicant hypoglycemia does not
cardiovascular risk factors and were
microvascular benets in previously become a barrier.
randomized to intensive glycemic
intensively treated subjects, even Cardiovascular Disease Outcomes control (goal A1C ,6%) or standard
though their glycemic control CVD is a more common cause of death glycemic control (goal A1C 78%). The
approximated that of previous standard than microvascular complications in glycemic control comparison was halted
arm subjects during follow-up. populations with diabetes. However, it early due to an increased mortality rate
Kumamoto and UK Prospective
is less clearly impacted by hyperglycemia in the intensive compared with the
Diabetes Study
levels or intensity of glycemic control. In standard arm (1.41 vs. 1.14%/year;
The Kumamoto (84) and UK Prospective the DCCT, there was a trend toward lower hazard ratio [HR] 1.22 [95% CI 1.01
Diabetes Study (UKPDS) (85,86) risk of CVD events with intensive control. 1.46]); with a similar increase in
conrmed that intensive glycemic In the 9-year post-DCCT follow-up of the cardiovascular deaths. Initial analysis of
control was associated with signicantly EDIC cohort, participants previously the ACCORD data (evaluating variables
decreased rates of microvascular and randomized to the intensive arm had a including weight gain, use of any specic
neuropathic complications in type 2 signicant 57% reduction in the risk of drug or drug combination, and
diabetic patients. Long-term follow-up nonfatal myocardial infarction (MI), hypoglycemia) did not identify a clear
of the UKPDS cohorts showed enduring stroke, or CVD death compared with those explanation for the excess mortality in
effects of early glycemic control on most previously in the standard arm (92). The the intensive arm (91). A subsequent
microvascular complications (87). Three benet of intensive glycemic control in this analysis showed no increase in mortality
landmark trials (ACCORD, ADVANCE, type 1 diabetic cohort has recently been in the intensive arm participants who
and VADT, described in further detail shown to persist for several decades (93). achieved A1C levels below 7%, nor in
below) were designed to examine the In type 2 diabetes, there is evidence that those who lowered their A1C quickly
impact of intensive A1C control on CVD more intensive treatment of glycemia in after trial enrollment. There was no A1C
outcomes and showed that lower A1C newly diagnosed patients may reduce long- level at which intensive versus standard
levels were associated with reduced term CVD rates. During the UKPDS trial, arm participants had signicantly
onset or progression of microvascular there was a 16% reduction in CVD events lower mortality. The highest risk for
complications (8890). (combined fatal or nonfatal MI and sudden mortality was observed in intensive arm
death) in the intensive glycemic control participants with the highest A1C levels
Epidemiological analyses of the DCCT
arm that did not reach statistical (95). Severe hypoglycemia was
and UKPDS (76,77) demonstrate a
curvilinear relationship between signicance (P 5 0.052), and there was no signicantly more likely in participants
suggestion of benet on other CVD randomized to the intensive glycemic
A1C and microvascular complications.
outcomes (e.g., stroke). However, after control arm. Unlike the DCCT, where
Such analyses suggest that, on a
10 years of follow-up, those originally lower achieved A1C levels were related
population level, the greatest number of
randomized to intensive glycemic control to signicantly increased rates of severe
complications will be averted by taking
had signicant long-term reductions in MI hypoglycemia, in ACCORD every 1%
patients from very poor control to fair/
(15% with sulfonylurea or insulin as initial decline in A1C from baseline to 4
good control. These analyses also
pharmacotherapy, 33% with metformin as months into the trial was associated
suggest that further lowering of A1C
initial pharmacotherapy) and in all-cause with a signicant decrease in the rate of
from 7 to 6% is associated with further
mortality (13% and 27%, respectively) (87). severe hypoglycemia in both arms (95).
reduction in the risk of microvascular
complications, though the absolute risk The Action to Control Cardiovascular Risk ADVANCE
reductions become much smaller. Given in Diabetes (ACCORD), Action in Diabetes The primary outcome of ADVANCE was a
the substantially increased risk of and Vascular Disease: Preterax and combination of microvascular events
hypoglycemia in type 1 diabetes trials, Diamicron Modied Release Controlled (nephropathy and retinopathy) and
and now seen in recent type 2 diabetes Evaluation (ADVANCE), and the Veterans major adverse cardiovascular events
trials, the risks of lower glycemic targets Affairs Diabetes Trial (VADT) studies (MI, stroke, and cardiovascular death).
may outweigh the potential benets on suggested no signicant reduction in CVD Intensive glycemic control (A1C ,6.5%,
microvascular complications on a outcomes with intensive glycemic control vs. treatment to local standards)
population level. The concerning in participants who had more advanced signicantly reduced the primary end
mortality ndings in the ACCORD trial type 2 diabetes than UKPDS participants. point, primarily due to a signicant
(91) and the relatively much greater All three trials were conducted in reduction in the microvascular
effort required to achieve near- participants with more long-standing outcome, specically development of
euglycemia should also be considered diabetes (mean duration 811 years) and albuminuria (.300 mg/24 h), with
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care.diabetesjournals.org Position Statement S25

no signicant reduction in the advanced atherosclerosis, and advanced associated with increased cardiovascular
macrovascular outcome. There was no age/frailty may benet from less risk independent of FPG in some
difference in overall or cardiovascular aggressive targets. Providers should be epidemiological studies. In diabetic
mortality between the two arms (89). vigilant in preventing severe subjects, surrogate measures of vascular
hypoglycemia in patients with advanced pathology, such as endothelial
VADT dysfunction, are negatively affected by
disease and should not aggressively
The primary outcome of the VADT was a postprandial hyperglycemia (101). It is
attempt to achieve near-normal A1C
composite of CVD events. The trial clear that postprandial hyperglycemia,
levels in patients in whom such targets
randomized type 2 diabetic participants like preprandial hyperglycemia,
cannot be safely and reasonably
who were uncontrolled on insulin or on
achieved. Severe or frequent contributes to elevated A1C levels, with
maximal dose oral agents (median entry
hypoglycemia is an absolute indication its relative contribution being greater at
A1C 9.4%) to a strategy of intensive
for the modication of treatment A1C levels that are closer to 7%. However,
glycemic control (goal A1C ,6.0%) or
regimens, including setting higher outcome studies have clearly shown
standard glycemic control, with a
glycemic goals. Many factors, including A1C to be the primary predictor of
planned A1C separation of at least 1.5%.
patient preferences, should be taken into complications, and landmark glycemic
The cumulative primary outcome was
account when developing a patients control trials such as the DCCT and UKPDS
nonsignicantly lower in the intensive
individualized goals (99) (Fig. 1). relied overwhelmingly on preprandial
arm (88). An ancillary study of the VADT
SMBG. Additionally, an RCT in patients
demonstrated that intensive glycemic
Glycemic Goals with known CVD found no CVD benet of
control signicantly reduced the
Recommended glycemic goals for many insulin regimens targeting postprandial
primary CVD outcome in individuals
nonpregnant adults are shown in glucose compared with those targeting
with less atherosclerosis at baseline but
Table 9. The recommendations are preprandial glucose (102). A reasonable
not in persons with more extensive
based on those for A1C values, with recommendation for postprandial testing
baseline atherosclerosis (96). A post hoc
blood glucose levels that appear to and targets is that for individuals who
analysis showed that mortality in the
correlate with achievement of an A1C of have premeal glucose values within
intensive versus standard glycemic
,7%. The issue of pre- versus target but have A1C values above
control arm was related to duration of
postprandial SMBG targets is complex target, monitoring postprandial plasma
diabetes at study enrollment. Those
(100). Elevated postchallenge (2-h glucose (PPG) 12 h after the start of the
with diabetes duration less than 15
OGTT) glucose values have been meal and treatment aimed at reducing
years had a mortality benet in the
intensive arm, while those with duration
of 20 years or more had higher mortality
in the intensive arm (97).
The evidence for a cardiovascular
benet of intensive glycemic control
primarily rests on long-term follow-up
of study cohorts treated early in the
course of type 1 and type 2 diabetes,
and a subset analyses of ACCORD,
ADVANCE, and VADT. A group-level
meta-analysis of the latter three trials
suggests that glucose lowering has a
modest (9%) but statistically signicant
reduction in major CVD outcomes,
primarily nonfatal MI, with no
signicant effect on mortality. However,
heterogeneity of the mortality effects
across studies was noted. A prespecied
subgroup analysis suggested that major
CVD outcome reduction occurred in
patients without known CVD at baseline
(HR 0.84 [95% CI 0.740.94]) (98).
Conversely, the mortality ndings in
ACCORD and subgroup analyses of the Figure 1Approach to management of hyperglycemia. Depiction of the elements of decision
VADT suggest that the potential risks of making used to determine appropriate efforts to achieve glycemic targets. Characteristics/
intensive glycemic control may predicaments toward the left justify more stringent efforts to lower A1C, whereas those toward
the right are compatible with less stringent efforts. Where possible, such decisions should be
outweigh its benets in some patients. made in conjunction with the patient, reecting his or her preferences, needs, and values. This
Those with long duration of diabetes, scale is not designed to be applied rigidly but to be used as a broad construct to help guide
known history of severe hypoglycemia, clinical decisions. Adapted with permission from Ismail-Beigi et al. (99).
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S26 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Table 9Summary of glycemic recommendations for many nonpregnant 1. Use MDI injections (34 injections
adults with diabetes per day of basal and prandial insulin)
A1C ,7.0%* or CSII therapy.
Preprandial capillary plasma glucose 70130 mg/dL* (3.97.2 mmol/L) 2. Match prandial insulin to
Peak postprandial capillary plasma glucose ,180 mg/dL* (,10.0 mmol/L) carbohydrate intake, premeal
c *Goals should be individualized based on: blood glucose, and anticipated
c duration of diabetes activity.
c age/life expectancy 3. For most patients (especially
c comorbid conditions
with hypoglycemia), use insulin
c known CVD or advanced microvascular
complications
analogs.
c hypoglycemia unawareness 4. For patients with frequent
c individual patient considerations nocturnal hypoglycemia and/or
c More or less stringent glycemic goals hypoglycemia unawareness, use of
may be appropriate for individual patients sensor-augmented low glucose
c Postprandial glucose may be targeted if A1C
suspend threshold pump may be
goals are not met despite reaching
considered.
preprandial glucose goals
Postprandial glucose measurements should be made 12 h after the beginning of the meal,
generally peak levels in patients with diabetes. There are excellent reviews to guide
the initiation and management of
insulin therapy to achieve desired
PPG values to ,180 mg/dL may help (three to four injections per day of basal glycemic goals (105,107,108). Although
lower A1C. and prandial insulin) or continuous most studies of MDI versus pump
subcutaneous insulin infusion (CSII). A therapy have been small and of short
Glycemic goals for children are provided
c Most people with type 1 diabetes duration, a systematic review and
in Section VIII.A.1.a.
should be educated in how to match meta-analysis concluded that there
Glycemic Goals in Pregnant Women prandial insulin dose to carbohydrate were no systematic differences in A1C
The goals for glycemic control for intake, premeal blood glucose, and or severe hypoglycemia rates in
women with GDM are based on anticipated activity. E children and adults between the two
recommendations from the Fifth c Most people with type 1 diabetes forms of intensive insulin therapy (73).
International Workshop-Conference on should use insulin analogs to reduce Recently, a large randomized trial in
Gestational Diabetes Mellitus (103) and hypoglycemia risk. A type 1 diabetic patients with nocturnal
have the following targets for maternal hypoglycemia reported that sensor-
capillary glucose concentrations: Screening
augmented insulin pump therapy with
c Consider screening those with type 1
the threshold-suspend feature reduced
c Preprandial: #95 mg/dL (5.3 diabetes for other autoimmune
nocturnal hypoglycemia, without
mmol/L), and either: diseases (thyroid, vitamin B12
increasing glycated hemoglobin values
c 1-h postmeal: #140 mg/dL deciency, celiac) as appropriate. B
(74). Overall, intensive management
(7.8 mmol/L) or The DCCT clearly showed that intensive through pump therapy/CGM and active
c 2-h postmeal: #120 mg/dL insulin therapy (three or more injections patient/family participation should be
(6.7 mmol/L) per day of insulin, or CSII (or insulin strongly encouraged (109111). For
pump therapy) was a key part of selected individuals who have
For women with preexisting type 1 or
improved glycemia and better mastered carbohydrate counting,
type 2 diabetes who become pregnant,
outcomes (76,92). The study was carried education on the impact of protein and
the following are recommended as
out with short- and intermediate-acting fat on glycemic excursions can be
optimal glycemic goals, if they can be
human insulins. Despite better incorporated into diabetes
achieved without excessive
microvascular outcomes, intensive management (112).
hypoglycemia (104):
insulin therapy was associated with a
c Premeal, bedtime, and overnight high rate of severe hypoglycemia (62
Screening
glucose 6099 mg/dL (3.35.4 mmol/L) episodes per 100 patient-years of Because of the increased frequency of
c Peak postprandial glucose 100129 therapy). Since the DCCT, a number of other autoimmune diseases in type 1
mg/dL (5.47.1 mmol/L) rapid-acting and long-acting insulin diabetes, screening for thyroid
c A1C ,6.0% analogs have been developed. These dysfunction, vitamin B12 deciency, and
analogs are associated with less celiac disease should be considered
D. Pharmacological and Overall hypoglycemia with equal A1C lowering based on signs and symptoms. Periodic
Approaches to Treatment in type 1 diabetes (105,106). screening in asymptomatic individuals
1. Insulin Therapy for Type 1 Diabetes Recommended therapy for type 1 has been recommended, but the
c Most people with type 1 diabetes diabetes consists of the following effectiveness and optimal frequency are
should be treated with MDI injections components: unclear.
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care.diabetesjournals.org Position Statement S27

Figure 2Antihyperglycemic therapy in type 2 diabetes: general recommendations. DPP-4-i, DPP-4 inhibitor; Fxs, bone fractures; GI, gastrointestinal; GLP-1-
RA, GLP-1 receptor agonist; HF, heart failure; SU, sulfonylurea; TZD, thiazolidinedione. For further details, see ref. 113. Adapted with permission.

2. Pharmacological Therapy for Considerations include efcacy, cost, on body weight, and hypoglycemia risk.
Hyperglycemia in Type 2 Diabetes potential side effects, effects on The position statement reafrms
Recommendations weight, comorbidities, hypoglycemia metformin as the preferred initial agent,
c Metformin, if not contraindicated risk, and patient preferences. E barring contraindication or intolerance,
and if tolerated, is the preferred c Due to the progressive nature of type either in addition to lifestyle counseling
initial pharmacological agent for type 2 diabetes, insulin therapy is and support for weight loss and exercise,
2 diabetes. A eventually indicated for many or when lifestyle efforts alone have not
c In newly diagnosed type 2 diabetic patients with type 2 diabetes. B achieved or maintained glycemic goals.
patients with markedly symptomatic Metformin has a long-standing evidence
and/or elevated blood glucose levels The ADA and the European Association for base for efcacy and safety, is inexpensive,
or A1C, consider insulin therapy, with the Study of Diabetes (EASD) formed a and may reduce risk of cardiovascular
or without additional agents, from joint task force to evaluate the data and events (87). When metformin fails to
the outset. E develop recommendations for the use of achieve or maintain glycemic goals,
c If noninsulin monotherapy at antihyperglycemic agents in type 2 another agent should be added. Although
maximum tolerated dose does not diabetic patients (113). This 2012 position there are numerous trials comparing
achieve or maintain the A1C target statement is less prescriptive than prior dual therapy to metformin alone, few
over 3 months, add a second oral algorithms and discusses advantages and directly compare drugs as add-on
agent, a glucagon-like peptide 1 (GLP- disadvantages of the available medication therapy. Comparative effectiveness
1) receptor agonist, or insulin. A classes and considerations for their use. A meta-analyses (114) suggest that
c A patient-centered approach should patient-centered approach is stressed, overall, each new class of noninsulin
be used to guide choice of including patient preferences, cost and agents added to initial therapy lowers
pharmacological agents. potential side effects of each class, effects A1C around 0.91.1%.
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S28 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Many patients with type 2 diabetes carbohydrate, protein, and fat for all c In people with type 2 diabetes, a
eventually require and benet from people with diabetes B; therefore, Mediterranean-style, MUFA-rich
insulin therapy. The progressive nature macronutrient distribution should be eating pattern may benet glycemic
of type 2 diabetes and its therapies based on individualized assessment control and CVD risk factors and
should be regularly and objectively of current eating patterns, can therefore be recommended as
explained to patients. Providers should preferences, and metabolic goals. E an effective alternative to a lower-
avoid using insulin as a threat or c A variety of eating patterns fat, higher-carbohydrate eating
describing it as a failure or punishment. (combinations of different foods or pattern. B
Equipping patients with an algorithm for food groups) are acceptable for the c As recommended for the general
self-titration of insulin doses based on management of diabetes. Personal public, an increase in foods
SMBG results improves glycemic control preference (e.g., tradition, culture, containing long-chain n-3 fatty acids
in type 2 diabetic patients initiating religion, health beliefs and goals, (EPA and DHA) (from fatty sh)
insulin (115). Refer to the ADA-EASD economics) and metabolic goals and n-3 linolenic acid (ALA) is
position statement for more details on should be considered when recommended for individuals with
pharmacotherapy for hyperglycemia in recommending one eating pattern diabetes because of their benecial
type 2 diabetes (113) (Fig. 2). over another. E effects on lipoproteins, prevention of
heart disease, and associations with
Carbohydrate Amount and Quality
E. Medical Nutrition Therapy positive health outcomes in
General Recommendations c Monitoring carbohydrate intake, observational studies. B
whether by carbohydrate counting c The amount of dietary saturated fat,
c Nutrition therapy is recommended
or experience-based estimation, cholesterol, and trans fat
for all people with type 1 and type 2
remains a key strategy in achieving recommended for people with
diabetes as an effective component
of the overall treatment plan. A glycemic control. B diabetes is the same as that
c For good health, carbohydrate intake
c Individuals who have prediabetes or recommended for the general
diabetes should receive from vegetables, fruits, whole grains, population. C
individualized MNT as needed to legumes, and dairy products should
achieve treatment goals, preferably be advised over intake from other Supplements for Diabetes Management
provided by a registered dietitian carbohydrate sources, especially c There is no clear evidence of benet
familiar with the components of those that contain added fats, sugars, from vitamin or mineral
diabetes MNT. A or sodium. B supplementation in people with
c Substituting low-glycemic load foods
c Because diabetes nutrition therapy diabetes who do not have underlying
can result in cost savings B and for higher-glycemic load foods may deciencies. C
improved outcomes such as modestly improve glycemic control. C c Routine supplementation with
c People with diabetes should consume
reduction in A1C A, nutrition therapy antioxidants, such as vitamins E and C
should be adequately reimbursed by at least the amount of ber and whole and carotene, is not advised because of
insurance and other payers. E grains recommended for the general lack of evidence of efcacy and concern
public. C related to long-term safety. A
Energy Balance, Overweight, and Obesity c While substituting sucrose- c Evidence does not support
c For overweight or obese adults with containing foods for isocaloric recommending n-3 (EPA and DHA)
type 2 diabetes or at risk for diabetes, amounts of other carbohydrates may supplements for people with
reducing energy intake while have similar blood glucose effects, diabetes for the prevention or
maintaining a healthful eating consumption should be minimized to treatment of cardiovascular
pattern is recommended to promote avoid displacing nutrient-dense food events. A
weight loss. A choices. A c There is insufcient evidence to
c Modest weight loss may provide c People with diabetes and those at risk support the routine use of
clinical benets (improved glycemia, for diabetes should limit or avoid micronutrients such as chromium,
blood pressure, and/or lipids) in some intake of sugar-sweetened beverages magnesium, and vitamin D to
individuals with diabetes, especially (from any caloric sweetener including improve glycemic control in people
those early in the disease process. To high-fructose corn syrup and sucrose)
with diabetes. C
achieve modest weight loss, to reduce risk for weight gain and c There is insufcient evidence to
intensive lifestyle interventions worsening of cardiometabolic risk support the use of cinnamon or other
(counseling about nutrition therapy, prole. B
herbs/supplements for the treatment
physical activity, and behavior Dietary Fat Quantity and Quality of diabetes. C
change) with ongoing support are c It is reasonable for individualized
c Evidence is inconclusive for an ideal
recommended. A meal planning to include optimization
amount of total fat intake for people
Eating Patterns and Macronutrient with diabetes; therefore, goals should of food choices to meet
Distribution be individualized. C Fat quality recommended daily allowance/
c Evidence suggests that there is not an appears to be far more important dietary reference intake for all
ideal percentage of calories from than quantity. B micronutrients. E
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care.diabetesjournals.org Position Statement S29

Alcohol therapy or individualized education protein (158160). A variety of eating


c If adults with diabetes choose to sessions have reported A1C decreases patterns have been shown to be
drink alcohol, they should be advised of 0.31% for type 1 diabetes (117120) effective in managing diabetes,
to do so in moderation (one drink and 0.52% for type 2 diabetes including Mediterranean-style
per day or less for adult women and (85,121137). (144,146,169), Dietary Approaches to
two drinks per day or less for adult Individuals with type 1 diabetes should Stop Hypertension (DASH)-style (161),
men). E be offered intensive insulin therapy plant-based (vegan or vegetarian) (129),
c Alcohol consumption may place lower-fat (145), and
education using the carbohydrate-
people with diabetes at increased risk counting meal planning approach lower-carbohydrate patterns
for delayed hypoglycemia, especially (117,119,120,124,138140); this (144,163).
if taking insulin or insulin
approach has been shown to improve Studies examining the ideal amount of
secretagogues. Education and
glycemic control (139,141). Consistent carbohydrate intake for people with
awareness regarding the recognition
carbohydrate intake with respect to diabetes are inconclusive, although
and management of delayed
time and amount can result in improved monitoring carbohydrate intake and
hypoglycemia is warranted. C
glycemic control for individuals using considering the available insulin are key
Sodium xed daily insulin doses (142,143). A strategies for improving postprandial
c The recommendation for the general simple diabetes meal planning approach glucose control (117,142,143,158). The
population to reduce sodium to such as portion control or healthful food literature concerning glycemic index
,2,300 mg/day is also appropriate choices may be better suited for and glycemic load in individuals with
for people with diabetes. B individuals with health literacy and diabetes is complex, although
c For individuals with both diabetes numeracy concerns (125127). reductions in A1C of 20.2% to 20.5%
and hypertension, further reduction have been demonstrated in some
Weight loss of 28 kg may provide
in sodium intake should be studies. In many studies, it is often
clinical benets in those with type 2
individualized. B difcult to discern the independent
diabetes, especially early in the disease
Primary Prevention of Type 2 Diabetes process (144146). Weight loss studies effect of ber compared with that of
c Among individuals at high risk for have used a variety of energy-restricted glycemic index on glycemic control and
developing type 2 diabetes, eating patterns, with no clear evidence other outcomes. Improvements in CVD
structured programs that emphasize that one eating pattern or optimal risk measures are mixed (164). Recent
lifestyle changes that include macronutrient distribution was ideal. studies have shown modest effect of
moderate weight loss (7% of body Although several studies resulted in ber on lowering preprandial glucose
weight) and regular physical activity improvements in A1C at 1 year and mixed results on improving CVD risk
(150 min/week), with dietary (144,145,147149), not all weight loss factors. A systematic review (157) found
strategies including reduced calories interventions led to 1-year A1C consumption of whole grains was not
and reduced intake of dietary fat, can improvements (128,150154). The most associated with improvements in glycemic
reduce the risk for developing consistently identied changes in control in people with type 2 diabetes,
diabetes and are therefore cardiovascular risk factors were an although it may reduce systemic
recommended. A increase in HDL cholesterol (144,145, inammation. One study did nd a
c Individuals at high risk for type 2 potential benet of whole grain intake in
147,149,153,155), decrease in
diabetes should be encouraged to triglycerides (144,145,149,155,156) reducing mortality and CVD (165).
achieve the U.S. Department of and decrease in blood pressure Limited research exists concerning the
Agriculture (USDA) recommendation (144,145,147,151,153,155). ideal amount of fat for individuals with
for dietary ber (14 g ber/1,000 kcal) diabetes. The Institute of Medicine has
and foods containing whole grains Intensive lifestyle programs with
frequent follow-up are required to dened an acceptable macronutrient
(one-half of grain intake). B
achieve signicant reductions in excess distribution range (AMDR) for all adults
body weight and improve clinical for total fat of 2035% of energy with no
The ADA recently released an updated
indicators (145,146). Several studies tolerable upper intake level dened.
position statement on nutrition therapy
have attempted to identify the optimal This AMDR was based on evidence for
for adults living with diabetes (116).
mix of macronutrients for meal plans of CHD risk with a low intake of fat and high
Nutrition therapy is an integral
people with diabetes. However, a recent intake of carbohydrate, and evidence
component of diabetes prevention,
systematic review (157) found that for increased obesity and CHD with high
management, and self-management
education. All individuals with diabetes there was no ideal macronutrient intake of fat (166). The type of fatty
should receive individualized MNT distribution and that macronutrient acids consumed is more important than
preferably provided by a registered proportions should be individualized. total amount of fat when looking at
dietitian who is knowledgeable and Studies show that people with diabetes metabolic goals and risk of CVD
skilled in providing diabetes MNT. on average eat about 45% of their (146,167,168).
Comprehensive group diabetes calories from carbohydrate, ;3640% Multiple RCTs including patients with
education programs including nutrition of calories from fat, and ;1618% from type 2 diabetes have reported improved
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S30 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

glycemic control and/or blood lipids 2 diabetes (204) have warranted caution team to improve clinical outcomes,
when a Mediterranean-style, MUFA- for universal sodium restriction to 1,500 health status, and quality of life in a
rich eating pattern was consumed mg in this population. For individuals cost-effective manner (206).
(144,146,151,169171). Some of these with diabetes and hypertension, setting a DSME and DSMS are essential elements
studies also included caloric restriction, sodium intake goal of ,2,300 mg/day of diabetes care (207209), and the current
which may have contributed to should be considered only on an National Standards for Diabetes Self-
improvements in glycemic control or individual basis. Goal sodium intake Management Education and Support (206)
blood lipids (169,170). The ideal ratio of recommendations should take into are based on evidence for their benets.
n-6 to n-3 fatty acids has not been account palatability, availability, additional Education helps people with diabetes
determined; however, PUFA and MUFA cost of specialty low sodium products, and initiate effective self-management and
are recommended substitutes for the difculty of achieving both low sodium cope with diabetes when they are rst
saturated or trans fat (167,172). recommendations and a nutritionally diagnosed. Ongoing DSME and DSMS also
adequate diet (205). For complete
A recent systematic review (157) help people with diabetes maintain
discussion and references of all
concluded that supplementation with effective self-management throughout a
recommendations, see Nutrition Therapy
n-3 fatty acids did not improve lifetime of diabetes as they face new
Recommendations for the Management
glycemic control but that higher dose challenges and treatment advances
of Adults With Diabetes (116).
supplementation decreased become available. DSME enables patients
triglycerides in individuals with type 2 F. Diabetes Self-Management (including youth) to optimize metabolic
diabetes. Six short-duration RCTs Education and Support control, prevent and manage
comparing n-3 supplements to placebo Recommendations
complications, and maximize quality of life,
published since the systematic review in a cost-effective manner (208,210).
c People with diabetes should receive
reported minimal or no benecial Current best practice of DSME is a skills-
DSME and diabetes self-management
effects (173,174) or mixed/ based approach that focuses on helping
support (DSMS) according to National
inconsistent benecial effects those with diabetes make informed self-
Standards for Diabetes Self-
(175177) on CVD risk factors and management choices (206,208). DSME
Management Education and Support
other health issues. Three longer- has changed from a didactic approach
when their diabetes is diagnosed and
duration studies also reported mixed as needed thereafter. B focusing on providing information
outcomes (178180). Thus, RCTs do c Effective self-management and to more theoretically based
not support recommending n-3 quality of life are the key outcomes of empowerment models that focus on
supplements for primary or secondary DSME and DSMS and should be helping those with diabetes make
prevention of CVD. Little evidence has measured and monitored as part of informed self-management decisions
been published about the relationship care. C (208). Diabetes care has shifted to an
between dietary intake of saturated c DSME and DSMS should address approach that is more patient centered
fatty acids and dietary cholesterol and psychosocial issues, since emotional and places the person with diabetes and
glycemic control and CVD risk in people well-being is associated with positive his or her family at the center of the care
with diabetes. Therefore, people with diabetes outcomes. C model working in collaboration with
diabetes should follow the guidelines c DSME and DSMS programs are health care professionals. Patient-
for the general population for the appropriate venues for people with centered care is respectful of and
recommended intakes of saturated fat, prediabetes to receive education and responsive to individual patient
dietary cholesterol, and trans fat (167). support to develop and maintain preferences, needs, and values and
Published data on the effects of plant behaviors that can prevent or delay ensures that patient values guide all
stanols and sterols on CVD risk in the onset of diabetes. C decision making (211).
individuals with diabetes include four c Because DSME and DSMS can result
RCTs that reported benecial effects for in cost-savings and improved Evidence for the Benets of Diabetes
total, LDL, and non-HDL cholesterol outcomes B, DSME and DSMS should Self-Management Education and
(181184). be adequately reimbursed by third- Support
party payers. E Multiple studies have found that DSME
There is limited evidence that the use of is associated with improved diabetes
vitamin, mineral, or herbal supplements knowledge and improved self-care
DSME and DSMS are the ongoing
is necessary in the management of behavior (206,207), improved clinical
processes of facilitating the knowledge,
diabetes (185201). skill, and ability necessary for diabetes outcomes such as lower A1C (209,212
Limited studies have been published on self-care. This process incorporates the 216), lower self-reported weight (207),
sodium reduction in people with needs, goals, and life experiences of the improved quality of life (213,216,217),
diabetes. A recent Cochrane review person with diabetes. The overall healthy coping (218,219), and lower
found that decreasing sodium intake objectives of DSME and DSMS are to costs (220,221). Better outcomes were
reduces blood pressure in those with support informed decision making, self- reported for DSME interventions that
diabetes (202). However, two other care behaviors, problem solving, and were longer and included follow-up
studies in type 1 diabetes (203) and type active collaboration with the health care support (DSMS) (207,222224), that
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care.diabetesjournals.org Position Statement S31

were culturally (225,226) and age Reimbursement for Diabetes Self- improvements in A1C and in tness
appropriate (227,228) and were tailored Management Education and Support (248). Other benets include slowing
to individual needs and preferences, DSME, when provided by a program that the decline in mobility among
and that addressed psychosocial issues meets national standards for DSME and overweight patients with diabetes
and incorporated behavioral strategies is recognized by ADA or other approval (249). A joint position statement of ADA
(207,208,218,219,229231). Both bodies, is reimbursed as part of the and the American College of Sports
individual and group approaches have Medicare program as overseen by the Medicine summarizes the evidence for
been found effective (232,233). There is Centers for Medicare and Medicaid the benets of exercise in people with
growing evidence for the role of a Services (CMS). DSME is also covered type 2 diabetes (250).
community health workers (234) and by most health insurance plans.
peer (235239) and lay leaders (240) in Although DSMS has been shown to be Frequency and Type of Exercise
delivering DSME and DSMS as part of instrumental for improving outcomes, The U.S. Department of Health and
the DSME/S team (241). as described in Evidence for the Human Services Physical Activity
Benets of Diabetes Self-Management Guidelines for Americans (251) suggest
Diabetes education is associated with
Education and Support, and can be that adults over age 18 years do 150
increased use of primary and preventive
provided in formats such as phone calls min/week of moderate-intensity, or 75
services (220,242,243) and lower use of
and via telehealth, it currently has min/week of vigorous aerobic physical
acute, inpatient hospital services (220).
limited reimbursement as face-to-face activity, or an equivalent combination of
Patients who participate in diabetes
visits included as follow-up to DSME. the two. In addition, the guidelines
education are more likely to follow best
practice treatment recommendations, suggest that adults also do muscle-
G. Physical Activity strengthening activities that involve all
particularly among the Medicare
Recommendations
population, and have lower Medicare and major muscle groups 2 or more days/
c As is the case for all children, children week. The guidelines suggest that adults
commercial claim costs (221,242).
with diabetes or prediabetes should over age 65 years, or those with
The National Standards for Diabetes be encouraged to engage in at least disabilities, follow the adult guidelines if
Self-Management Education and 60 min of physical activity each day. B possible or (if this is not possible) be as
Support c Adults with diabetes should be advised physically active as they are able.
The National Standards for Diabetes to perform at least 150 min/week of Studies included in the meta-analysis of
Self-Management Education and Support moderate-intensity aerobic physical effects of exercise interventions on
are designed to dene quality DSME and activity (5070% of maximum heart glycemic control (246) had a mean of 3.4
DSMS and to assist diabetes educators rate), spread over at least 3 days/week sessions/week, with a mean of 49 min/
in a variety of settings to provide with no more than 2 consecutive days session. The DPP lifestyle intervention,
evidence-based education and self- without exercise. A which included 150 min/week of
management support (206). The c In the absence of contraindications, moderate-intensity exercise, had a
standards are reviewed and updated adults with type 2 diabetes should be benecial effect on glycemia in those
every 5 years by a task force representing encouraged to perform resistance with prediabetes. Therefore, it seems
key organizations involved in the eld of training at least twice per week. A reasonable to recommend that people
diabetes education and care. with diabetes follow the physical
Exercise is an important part of the
activity guidelines for the general
Diabetes Self-Management Education diabetes management plan. Regular
population.
and Support Providers and People exercise has been shown to improve
With Prediabetes blood glucose control, reduce Progressive resistance exercise
The standards for DSME and DSMS also cardiovascular risk factors, contribute to improves insulin sensitivity in older men
apply to the education and support of weight loss, and improve well-being. with type 2 diabetes to the same or
people with prediabetes. Currently, there Furthermore, regular exercise may even a greater extent as aerobic
are signicant barriers to the provision of prevent type 2 diabetes in high-risk exercise (252). Clinical trials have
education and support to those with individuals (2325). Structured exercise provided strong evidence for the A1C
prediabetes. However, the strategies for interventions of at least 8 weeks lowering value of resistance training in
supporting successful behavior change duration have been shown to lower A1C older adults with type 2 diabetes
and the healthy behaviors recommended by an average of 0.66% in people with (253,254), and for an additive benet of
for people with prediabetes are largely type 2 diabetes, even with no signicant combined aerobic and resistance
identical to those for people with diabetes. change in BMI (246). There are exercise in adults with type 2 diabetes
As barriers to care are overcome, considerable data for the health (255,256). In the absence of
providers of DSME and DSMS, given their benets (e.g., increased cardiovascular contraindications, patients with type 2
training and experience, are particularly tness, muscle strength, improved diabetes should be encouraged to do at
well equipped to assist people with insulin sensitivity, etc.) of regular least two weekly sessions of resistance
prediabetes in developing and maintaining physical activity for those with type 1 exercise (exercise with free weights or
behaviors that can prevent or delay the diabetes (247). Higher levels of exercise weight machines), with each session
onset of diabetes (206,244,245). intensity are associated with greater consisting of at least one set of ve or
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S32 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

more different resistance exercises Exercise in the Presence of Specic H. Psychosocial Assessment and Care
involving the large muscle groups (250). Long-Term Complications of Diabetes Recommendations

Pre-exercise Evaluation of the Retinopathy. In the presence of c It is reasonable to include assessment


Diabetic Patient proliferative diabetic retinopathy of the patients psychological and social
As discussed more fully in Section VI.A.5, (PDR) or severe non-PDR (NPDR), situation as an ongoing part of the
the area of screening asymptomatic vigorous aerobic or resistance medical management of diabetes. B
diabetic patients for coronary artery exercise may be contraindicated c Psychosocial screening and follow-up
disease (CAD) remains unclear. An ADA because of the risk of triggering may include, but are not limited to,
consensus statement on this issue vitreous hemorrhage or retinal attitudes about the illness,
concluded that routine screening is not detachment (259). expectations for medical
recommended (257). Providers should Peripheral Neuropathy. Decreased pain management and outcomes, affect/
use clinical judgment in this area. sensation and a higher pain threshold in mood, general and diabetes-related
Certainly, high-risk patients should be the extremities result in increased risk of quality of life, resources (nancial,
encouraged to start with short periods skin breakdown and infection and of social, and emotional), and
of low-intensity exercise and increase Charcot joint destruction with some psychiatric history. E
the intensity and duration slowly. c Routinely screen for psychosocial
forms of exercise. However, studies
Providers should assess patients for have shown that moderate-intensity problems such as depression and
conditions that might contraindicate walking may not lead to increased risk of diabetes-related distress, anxiety,
certain types of exercise or predispose foot ulcers or reulceration in those with eating disorders, and cognitive
to injury, such as uncontrolled peripheral neuropathy (260). In impairment. B
hypertension, severe autonomic addition, 150 min/week of moderate Emotional well-being is an important part
neuropathy, severe peripheral exercise was reported to improve of diabetes care and self-management.
neuropathy or history of foot lesions, outcomes in patients with milder forms Psychological and social problems can
and unstable proliferative retinopathy. of neuropathy (260a). All individuals impair the individuals (263265) or
The patients age and previous physical with peripheral neuropathy should wear familys ability (266) to carry out diabetes
activity level should be considered. For proper footwear and examine their feet care tasks and therefore compromise
type 1 diabetic patients, the provider daily to detect lesions early. Anyone health status. There are opportunities for
should customize the exercise regimen with a foot injury or open sore should be the clinician to routinely assess
to the individuals needs. Those with restricted to nonweight-bearing psychosocial status in a timely and
complications may require a more activities. efcient manner so that referral for
thorough evaluation (247). appropriate services can be
Autonomic Neuropathy. Autonomic
Exercise in the Presence of neuropathy can increase the risk of accomplished. A systematic review and
Nonoptimal Glycemic Control exercise-induced injury or adverse meta-analysis showed that psychosocial
Hyperglycemia. When people with type 1 event through decreased cardiac interventions modestly but signicantly
diabetes are deprived of insulin for responsiveness to exercise, postural improved A1C (standardized mean
1248 h and are ketotic, exercise can hypotension, impaired thermoregulation, difference 20.29%) and mental health
worsen hyperglycemia and ketosis impaired night vision due to impaired outcomes. However, there was a limited
(258); therefore, vigorous activity papillary reaction, and higher association between the effects on A1C
should be avoided in the presence of susceptibility to hypoglycemia (454). and mental health, and no intervention
ketosis. However, it is not necessary to Cardiovascular autonomic neuropathy characteristics predicted benet on both
postpone exercise based simply on (CAN) is also an independent risk outcomes (267).
hyperglycemia, provided the patient factor for cardiovascular death and Screening
feels well and urine and/or blood silent myocardial ischemia (261). Key opportunities for routine screening of
ketones are negative. Therefore, individuals with diabetic psychosocial status occur at diagnosis,
Hypoglycemia. In individuals taking autonomic neuropathy should during regularly scheduled management
insulin and/or insulin secretagogues, undergo cardiac investigation before visits, during hospitalizations, with the
physical activity can cause hypoglycemia beginning physical activity more discovery of complications, or when
if medication dose or carbohydrate intense than that to which they are problems with glucose control, quality of
consumption is not altered. For accustomed. life, or self-management are identied.
individuals on these therapies, added Albuminuria and Nephropathy. Physical Patients are likely to exhibit psychological
carbohydrate should be ingested if pre- activity can acutely increase urinary vulnerability at diagnosis and when their
exercise glucose levels are ,100 mg/dL protein excretion. However, there is no medical status changes, e.g., end of the
(5.6 mmol/L). Hypoglycemia is less evidence that vigorous exercise honeymoon period, when the need for
common in diabetic individuals who are increases the rate of progression of intensied treatment is evident, and
not treated with insulin or insulin diabetic kidney disease and likely no when complications are discovered.
secretagogues, and no preventive need for any specic exercise Depression affects about 2025% of
measures for hypoglycemia are usually restrictions for people with diabetic people with diabetes (268) and increases
advised in these cases. kidney disease (262). the risk for MI and post-MI (269) and
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care.diabetesjournals.org Position Statement S33

all-cause mortality (270). There appears interventions to enhance self- with hyperglycemia in the hospital, see
to be a bidirectional relationship with management and address severe Section IX.A. For further information on
both diabetes (271) and metabolic distress have demonstrated efcacy in management of DKA or hyperglycemic
syndrome (272) and depression. diabetes-related distress (219). nonketotic hyperosmolar state, refer to
Diabetes-related distress is distinct from the ADA statement on hyperglycemic
I. When Treatment Goals Are Not Met crises (288).
clinical depression and is very common
Some people with diabetes and their
(273276) among people with diabetes
health care providers may not achieve K. Hypoglycemia
and their family members (266).
the desired treatment goals (Table 9). Recommendations
Prevalence is reported as 1845%, with
Rethinking the treatment regimen may c Individuals at risk for hypoglycemia
an incidence of 3848% over 18 months.
require assessment of barriers including should be asked about symptomatic
High levels of distress are signicantly
income, health literacy, diabetes- and asymptomatic hypoglycemia at
linked to A1C, self-efcacy, dietary and
related distress, depression, and each encounter. C
exercise behaviors (219,274), and
competing demands, including those c Glucose (1520 g) is the preferred
medication taking (277). Other issues
related to family responsibilities and treatment for the conscious
known to impact self-management and
dynamics. Other strategies may include individual with hypoglycemia,
health outcomes include but are not
culturally appropriate and enhanced although any form of carbohydrate
limited to attitudes about the illness,
DSME and DSMS, comanagement with a that contains glucose may be used.
expectations for medical management
diabetes team, referral to a medical After 15 min of treatment, if SMBG
and outcomes, anxiety, general and
social worker for assistance with shows continued hypoglycemia, the
diabetes-related quality of life, resources
insurance coverage, assessing treatment should be repeated. Once
(nancial, social, and emotional) (278)
medication-taking behaviors, or change SMBG returns to normal, the
and psychiatric history (279,280).
in pharmacological therapy. Initiation of individual should consume a meal or
Screening tools are available for a number
or increase in SMBG, use of CGM, snack to prevent recurrence of
of these areas (229,281,282).
frequent contact with the patient, or hypoglycemia. E
referral to a mental health professional c Glucagon should be prescribed for
Referral to Mental Health Specialist or physician with special expertise in all individuals at signicant risk of
Indications for referral to a mental diabetes may be useful. severe hypoglycemia, and caregivers
health specialist familiar with diabetes or family members of these
management may include gross J. Intercurrent Illness individuals should be instructed on
disregard for the medical regimen (by The stress of illness, trauma, and/or its administration. Glucagon
self or others) (283), depression, surgery frequently aggravates glycemic administration is not limited to
possibility of self-harm, debilitating control and may precipitate DKA or health care professionals. E
anxiety (alone or with depression), nonketotic hyperosmolar state, life- c Hypoglycemia unawareness or one or
indications of an eating disorder (284), threatening conditions that require more episodes of severe hypoglycemia
or cognitive functioning that immediate medical care to prevent should trigger re-evaluation of the
signicantly impairs judgment. It is complications and death. Any condition treatment regimen. E
preferable to incorporate leading to deterioration in glycemic c Insulin-treated patients with
psychological assessment and control necessitates more frequent hypoglycemia unawareness or an
treatment into routine care rather than monitoring of blood glucose and (in episode of severe hypoglycemia
waiting for a specic problem or ketosis-prone patients) urine or blood should be advised to raise their
deterioration in metabolic or ketones. If accompanied by ketosis, glycemic targets to strictly avoid
psychological status (229,273). In the vomiting, or alteration in level of further hypoglycemia for at least
recent DAWN2 study, signicant consciousness, marked hyperglycemia several weeks, to partially reverse
diabetes-related distress was reported requires temporary adjustment of the hypoglycemia unawareness and
by 44.6% of the participants, but only treatment regimen and immediate reduce risk of future episodes. A
23.7% reported that their health care interaction with the diabetes care team. c Ongoing assessment of cognitive
team asked them how diabetes The patient treated with noninsulin function is suggested with increased
impacted their life (273). therapies or MNT alone may vigilance for hypoglycemia by the
Although the clinician may not feel temporarily require insulin. Adequate clinician, patient, and caregivers if
qualied to treat psychological uid and caloric intake must be assured. low cognition and/or declining
problems (285), using the patient- Infection or dehydration is more likely cognition is found. B
provider relationship as a foundation to necessitate hospitalization of the
can increase the likelihood that the person with diabetes than the person Hypoglycemia is the leading limiting
patient will accept referral for other without diabetes. factor in the glycemic management of
services. Collaborative care The hospitalized patient should be type 1 and insulin-treated type 2
interventions and use of a team treated by a physician with expertise in diabetes (289). Mild hypoglycemia may
approach have demonstrated efcacy in diabetes management. For further be inconvenient or frightening to
diabetes and depression (286,287), and information on management of patients patients with diabetes. Severe
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S34 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

hypoglycemia can cause acute harm to Hypoglycemia treatment requires patients (296). Hence, patients with one
the person with diabetes or others, ingestion of glucose- or carbohydrate- or more episodes of severe hypoglycemia
especially if it causes falls, motor vehicle containing foods. The acute glycemic may benet from at least short-term
accidents, or other injury. A large cohort response correlates better with the relaxation of glycemic targets.
study suggested that among older glucose content than with the L. Bariatric Surgery
adults with type 2 diabetes, a history of carbohydrate content of the food. Pure
Recommendations
severe hypoglycemia was associated glucose is the preferred treatment, but
c Bariatric surgery may be considered
with greater risk of dementia (290). any form of carbohydrate that contains
glucose will raise blood glucose. Added for adults with BMI .35 kg/m2 and
Conversely, in a substudy of the
fat may retard and then prolong the acute type 2 diabetes, especially if diabetes
ACCORD trial, cognitive impairment at
glycemic response. Ongoing insulin or associated comorbidities are
baseline or decline in cognitive function
activity or insulin secretagogues may lead difcult to control with lifestyle and
during the trial was signicantly
to recurrent hypoglycemia unless further pharmacological therapy. B
associated with subsequent episodes of
c Patients with type 2 diabetes who
severe hypoglycemia (291). Evidence food is ingested after recovery.
have undergone bariatric surgery
from the DCCT/EDIC trial, which
Glucagon need lifelong lifestyle support and
involved younger adults and
Those in close contact with, or having medical monitoring. B
adolescents with type 1 diabetes,
custodial care of, people with c Although small trials have shown
suggested no association of frequency
hypoglycemia-prone diabetes (family glycemic benet of bariatric surgery
of severe hypoglycemia with cognitive
members, roommates, school in patients with type 2 diabetes and
decline (292), as discussed in Section
personnel, child care providers, BMI 3035 kg/m2, there is currently
VIII.A.1.a.
correctional institution staff, or insufcient evidence to generally
As described in Section V.b.2, severe coworkers) should be instructed on use recommend surgery in patients with
hypoglycemia was associated with of glucagon kits. An individual does not BMI ,35 kg/m2 outside of a research
mortality in participants in both the need to be a health care professional to protocol. E
standard and intensive glycemia arms safely administer glucagon. A glucagon c The long-term benets, cost-
of the ACCORD trial, but the kit requires a prescription. Care should effectiveness, and risks of bariatric
relationships with achieved A1C and be taken to ensure that glucagon kits are surgery in individuals with type 2
treatment intensity were not not expired. diabetes should be studied in well-
straightforward. An association of designed controlled trials with
Hypoglycemia Prevention
severe hypoglycemia with mortality optimal medical and lifestyle therapy
Hypoglycemia prevention is a critical
was also found in the ADVANCE trial as the comparator. E
component of diabetes management.
(293). An association of self-reported
SMBG and, for some patients, CGM are
severe hypoglycemia with 5-year Bariatric and metabolic surgeries, either
key tools to assess therapy and detect
mortality has also been reported in gastric banding or procedures that involve
incipient hypoglycemia. Patients should
clinical practice (294). bypassing, transposing, or resecting
understand situations that increase their
In 2013, ADA and The Endocrine Society sections of the small intestine, when part
risk of hypoglycemia, such as when
published a consensus report on the of a comprehensive team approach, can
fasting for tests or procedures, during or
impact and treatment of hypoglycemia be an effective weight loss treatment for
after intense exercise, and during sleep,
on diabetic patients. Severe severe obesity, and national guidelines
and that hypoglycemia may increase the
hypoglycemia was dened as an event support its consideration for people with
risk of harm to self or others, such as with
requiring assistance of another person. type 2 diabetes who have BMI exceeding
driving. Teaching people with diabetes to
Young children with type 1 diabetes and 35 kg/m2.
balance insulin use, carbohydrate intake,
the elderly were noted as particularly and exercise is a necessary but not Advantages
vulnerable due to their limited ability to always sufcient strategy for prevention. Bariatric surgery has been shown to lead
recognize hypoglycemic symptoms and In type 1 diabetes and severely insulin- to near- or complete normalization of
effectively communicate their needs. decient type 2 diabetes, hypoglycemia glycemia in ;4095% of patients with
The report recommended that short- unawareness, or hypoglycemia- type 2 diabetes, depending on the study
acting insulin sliding scales, often used in associated autonomic failure, can and the surgical procedure (297300).
long-term care facilities, should be severely compromise stringent diabetes A meta-analysis of bariatric surgery
avoided and complex regimens control and quality of life. The decient studies involving 3,188 patients with
simplied. Individualized patient counter-regulatory hormone release and diabetes reported that 78% had
education, dietary intervention (e.g., autonomic responses in this syndrome remission of diabetes (normalization of
bedtime snack to prevent overnight are both risk factors for, and caused by, blood glucose levels in the absence of
hypoglycemia), exercise management, hypoglycemia. A corollary to this vicious medications) and that the remission
medication adjustment, glucose cycle is that several weeks of avoidance rates were sustained in studies that had
monitoring, and routine clinical of hypoglycemia has been demonstrated follow-up exceeding 2 years (301).
surveillance may improve patient to improve counter-regulation and Remission rates tend to be lower with
outcomes (295). awareness to some extent in many procedures that only constrict the
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care.diabetesjournals.org Position Statement S35

stomach and higher with those that decreased mortality compared with hospitalizations for inuenza and its
bypass portions of the small intestine. usual care (mean follow-up 6.7 years) complications. People with diabetes
Additionally, intestinal bypass procedures (309). A study that followed patients may be at increased risk of the
may have glycemic effects that are who had undergone laparoscopic bacteremic form of pneumococcal
independent of their effects on weight, adjustable gastric banding (LAGB) for infection and have been reported to
perhaps involving the incretin axis. 12 years found that 60% were satised have a high risk of nosocomial
There is also evidence for diabetes with the procedure. Nearly one out of bacteremia, which has a mortality rate
remission following bariatric surgery in three patients experienced band erosion, as high as 50% (311).
persons with type 2 diabetes who are and almost half had required removal of Safe and effective vaccines that greatly
less severely obese. One randomized their bands. The authors conclusion was reduce the risk of serious complications
trial compared adjustable gastric that LAGB appears to result in relatively from these diseases are available
banding to best available medical and poor long-term outcomes (310). (312,313). In a case-control series,
lifestyle therapy in subjects with type 2 Understanding the mechanisms of inuenza vaccine was shown to reduce
diabetes and BMI 3040 kg/m2 (302). glycemic improvement, long-term diabetes-related hospital admission by
Overall, 73% of surgically treated benets, and risks of bariatric surgery in as much as 79% during u epidemics
patients achieved remission of their individuals with type 2 diabetes, (312). There is sufcient evidence to
diabetes, compared with 13% of those especially those who are not severely support that people with diabetes
treated medically. The latter group lost obese, will require well designed clinical have appropriate serologic and clinical
only 1.7% of body weight, suggesting trials, with optimal medical and lifestyle responses to these vaccinations.
that their therapy was not optimal. therapy, and cardiovascular risk factors as The CDC Advisory Committee on
Overall the trial had 60 subjects, and the comparator. Immunization Practices recommends
only 13 had a BMI under 35 kg/m2, inuenza and pneumococcal vaccines for
M. Immunization
making it difcult to generalize these all individuals with diabetes (http://
Recommendations
results widely to diabetic patients who www.cdc.gov/vaccines/recs/).
c Annually provide an inuenza vaccine
are less severely obese or with longer Hepatitis B Vaccine
duration of diabetes. In a recent to all diabetic patients $6 months of
age. C Late in 2012, the Advisory Committee
nonrandomized study of 66 people with on Immunization Practices of the CDC
c Administer pneumococcal
BMI 3035 kg/m2, 88% of participants recommended that all previously
had remission of their type 2 diabetes polysaccharide vaccine to all diabetic
patients $2 years of age. A one-time unvaccinated adults with diabetes aged
up to 6 years after surgery (303). 1959 years be vaccinated against
revaccination is recommended for
Disadvantages individuals .65 years of age who hepatitis B virus (HBV) as soon as
Bariatric surgery is costly in the short have been immunized .5 years ago. possible after a diagnosis of diabetes is
term and has associated risks. Morbidity Other indications for repeat made. Additionally, after assessing risk
and mortality rates directly related to the vaccination include nephrotic and likelihood of an adequate immune
surgery have been reduced considerably syndrome, chronic renal disease, and response, vaccinations for those aged
in recent years, with 30-day mortality other immunocompromised states, 60 years and over should also be
rates now 0.28%, similar to those of such as after transplantation. C considered (314). At least 29 outbreaks
laparoscopic cholecystectomy (304). c Administer hepatitis B vaccination to of HBV in long-term care facilities and
Longer-term concerns include vitamin unvaccinated adults with diabetes who hospitals have been reported to the
and mineral deciencies, osteoporosis, are aged 1959 years. C CDC, with the majority involving adults
and rare but often severe hypoglycemia c Consider administering hepatitis B with diabetes receiving assisted blood
from insulin hypersecretion. Cohort vaccination to unvaccinated adults glucose monitoring, in which such
studies attempting to match subjects with diabetes who are aged $60 monitoring is done by a health care
suggest that the procedure may reduce years. C professional with responsibility for
longer-term mortality rates (305). more than one patient. HBV is highly
Retrospective analyses and modeling Inuenza and pneumonia are common, transmissible and stable for long
studies suggest that these procedures preventable infectious diseases periods of time on surfaces such as
may be cost-effective for patients with associated with high mortality and lancing devices and blood glucose
type 2 diabetes, when one considers morbidity in the elderly and in people meters, even when no blood is visible.
reduction in subsequent health care costs with chronic diseases. Though there are Blood sufcient to transmit the virus
(297,306308). limited studies reporting the morbidity has also been found in the reservoirs of
Caution about the benets of bariatric and mortality of inuenza and insulin pens, resulting in warnings
surgery is warranted. A propensity pneumococcal pneumonia specically in against sharing such devices between
score-adjusted analyses of older people with diabetes, observational patients.
severely obese patients with high studies of patients with a variety of CDC analyses suggest that, excluding
baseline mortality in Veterans Affairs chronic illnesses, including diabetes, persons with HBV-related risk
Medical Centers found that bariatric show that these conditions are behaviors, acute HBV infection is about
surgery was not associated with associated with an increase in twice as high among adults with
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S36 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

diabetes aged 23 years and over 1. Hypertension/Blood Pressure Control c In pregnant patients with diabetes
compared with adults without diabetes. Recommendations and chronic hypertension, blood
Seroprevalence of antibody to HBV core Screening and Diagnosis pressure target goals of 110129/
antigen, suggesting past or current c Blood pressure should be measured 6579 mmHg are suggested in the
infection, is 60% higher among adults at every routine visit. Patients found interest of long-term maternal health
with diabetes than those without, and to have elevated blood pressure and minimizing impaired fetal
there is some evidence that diabetes should have blood pressure growth. ACE inhibitors and ARBs are
imparts a higher HBV case fatality rate. conrmed on a separate day. B contraindicated during pregnancy. E
The age differentiation in the Goals
recommendations stems from CDC Hypertension is a common comorbidity
c People with diabetes and
economic models suggesting that of diabetes, affecting the majority of
hypertension should be treated to a patients, with prevalence depending on
vaccination of adults with diabetes
systolic blood pressure (SBP) goal of type of diabetes, age, obesity, and
who were aged 2059 years would cost
,140 mmHg. B ethnicity. Hypertension is a major risk
an estimated $75,000 per quality-
c Lower systolic targets, such as ,130 factor for both CVD and microvascular
adjusted life-year saved, while cost per
mmHg, may be appropriate for complications. In type 1 diabetes,
quality-adjusted life-year saved
certain individuals, such as younger hypertension is often the result of
increased signicantly at higher ages.
patients, if it can be achieved without underlying nephropathy, while in type 2
In addition to competing causes of
undue treatment burden. C diabetes it usually coexists with other
mortality in older adults, the immune
c Patients with diabetes should be
response to the vaccine declines with cardiometabolic risk factors.
treated to a diastolic blood pressure
age (314).
(DBP) ,80 mmHg. B Screening and Diagnosis
These new recommendations regarding Blood pressure measurement should be
Treatment
HBV vaccinations serve as a reminder to done by a trained individual and follow
clinicians that children and adults with c Patients with blood pressure .120/80 the guidelines established for
diabetes need a number of vaccinations, mmHg should be advised on lifestyle nondiabetic individuals: measurement
both those specically indicated changes to reduce blood pressure. B in the seated position, with feet on the
c Patients with conrmed blood oor and arm supported at heart level,
because of diabetes as well as those
recommended for the general pressure higher than 140/80 mmHg after 5 min of rest. Cuff size should be
population (http://www.cdc.gov/ should, in addition to lifestyle appropriate for the upper arm
vaccines/recs/). therapy, have prompt initiation and circumference. Elevated values should
timely subsequent titration of be conrmed on a separate day.
VI. PREVENTION AND pharmacological therapy to achieve
blood pressure goals. B Home blood pressure self-monitoring and
MANAGEMENT OF DIABETES 24-h ambulatory blood pressure
c Lifestyle therapy for elevated blood
COMPLICATIONS monitoring may provide additional
pressure consists of weight loss, if
For prevention and management of
overweight; DASH-style dietary evidence of white coat and masked
diabetes complications in children and hypertension and other discrepancies
pattern including reducing sodium
adolescents, please refer to Section VIII.
and increasing potassium intake; between ofce and true blood pressure.
Diabetes Care in Specic Populations. Studies in nondiabetic populations found
moderation of alcohol intake; and
increased physical activity. B that home measurements may better
A. Cardiovascular Disease
CVD is the major cause of morbidity and c Pharmacological therapy for patients correlate with CVD risk than ofce
mortality for individuals with diabetes, with diabetes and hypertension measurements (318,319). However, most
and the largest contributor to the direct should comprise a regimen that of the evidence of benets of
and indirect costs of diabetes. The includes either an ACE inhibitor or an hypertension treatment in people with
common conditions coexisting with type angiotensin receptor blocker (ARB). If diabetes is based on ofce measurements.
2 diabetes (e.g., hypertension and one class is not tolerated, the other Treatment Goals
dyslipidemia) are clear risk factors for should be substituted. C Epidemiological analyses show that
CVD, and diabetes itself confers c Multiple-drug therapy (two or more blood pressures .115/75 mmHg are
independent risk. Numerous studies agents at maximal doses) is generally associated with increased
have shown the efcacy of controlling required to achieve blood pressure cardiovascular event rates and mortality
individual cardiovascular risk factors in targets. B in individuals with diabetes (320322)
preventing or slowing CVD in people c Administer one or more and that SBP .120 mmHg predict long-
with diabetes. Large benets are seen antihypertensive medications at term end-stage renal disease (ESRD).
when multiple risk factors are addressed bedtime. A Randomized clinical trials have
globally (315,316). There is evidence c If ACE inhibitors, ARBs, or diuretics demonstrated the benet (reduction of
that measures of 10-year CHD risk are used, serum creatinine/estimated CHD events, stroke, and nephropathy)
among U.S. adults with diabetes have glomerular ltration rate (eGFR) and of lowering blood pressure to ,140
improved signicantly over the past serum potassium levels should be mmHg systolic and ,80 mmHg
decade (317). monitored. E diastolic in individuals with diabetes
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care.diabetesjournals.org Position Statement S37

(320,323325). There is limited evidence inappropriate for dening blood of reducing sodium intake (,1,500 mg/
for the benets of lower SBP targets. pressure targets, since sicker patients day) and excess body weight; increasing
The ACCORD trial examined whether a may have low blood pressures or, consumption of fruits, vegetables (810
lower SBP of ,120 mmHg provides conversely, healthier or more adherent servings per day), and low-fat dairy
greater cardiovascular protection patients may achieve goals more products (23 servings per day);
than an SBP level of 130140 mmHg in readily. A recent meta-analysis of avoiding excessive alcohol consumption
randomized trials of adults with type 2 (no more than 2 servings per day in men
patients with type 2 diabetes at high risk
diabetes comparing prespecied blood and no more than 1 serving per day in
for CVD (326). The HR for the primary
pressure targets found no signicant women) (332); and increasing activity
end point (nonfatal MI, nonfatal stroke,
reduction in mortality or nonfatal MI. levels (320). These nonpharmacological
and CVD death) in the intensive (blood
There was a statistically signicant 35% strategies may also positively affect
pressure 11/64 on 3.4 medications)
relative reduction in stroke, but the glycemia and lipid control and as a result
versus standard group (blood pressure
absolute risk reduction was only 1% should be encouraged in those with
143/70 on 2.1 medications) was 0.88
(330). Microvascular complications even mildly elevated blood pressure.
(95% CI 0.731.06; P 5 0.20). Of the
were not examined. Another meta- Their effects on cardiovascular events
prespecied secondary end points, only
analysis that included both trials have not been established.
stroke and nonfatal stroke were comparing blood pressure goals and Nonpharmacological therapy is
statistically signicantly reduced by trials comparing treatment strategies reasonable in diabetic individuals with
intensive blood pressure treatment. concluded that a systolic treatment goal mildly elevated blood pressure (SBP
The number needed to treat to prevent of 130135 mmHg was acceptable. With .120 mmHg or DBP .80 mmHg). If the
one stroke over the course of 5 years goals ,130 mmHg, there were greater blood pressure is conrmed to be $140
with intensive blood pressure reductions in stroke, a 10% reduction in mmHg systolic and/or $80 mmHg
management was 89. Serious adverse mortality, but no reduction of other diastolic, pharmacological therapy
event rates (including syncope and CVD events and increased rates of should be initiated along with
hyperkalemia) were higher with serious adverse events. SBP ,130 nonpharmacological therapy (320).
intensive targets (3.3% vs. 1.3%; P 5 mmHg was associated with reduced Lowering of blood pressure with
0.001). Albuminuria rates were reduced onset and progression of albuminuria. regimens based on a variety of
with more intensive blood pressure However, there was heterogeneity in antihypertensive drugs, including ACE
goals, but there were no differences in the measure, rates of more advanced inhibitors, ARBs, b-blockers, diuretics,
renal function nor in other renal disease outcomes were not and calcium channel blockers, has been
microvascular complications. affected, and there were no signicant shown to be effective in reducing
The ADVANCE trial (treatment with an changes in retinopathy or neuropathy cardiovascular events. Several studies
ACE inhibitor and a thiazide-type diuretic) (331). suggested that ACE inhibitors may be
showed a reduced death rate but not in The clear body of evidence that SBP superior to dihydropyridine calcium
the composite macrovascular outcome. .140 mmHg is harmful suggests that channel blockers in reducing
However, the ADVANCE trial had no clinicians should promptly initiate and cardiovascular events (333335).
specied targets for the randomized titrate therapy in an ongoing fashion to However, several studies have shown
comparison and the mean SBP in the achieve and maintain SBP ,140 mmHg no specic advantage to ACE inhibitors
intensive group (135 mmHg) was not as in virtually all patients. Additionally, as initial treatment of hypertension in
low as the mean SBP even in the ACCORD patients with long life expectancy (in the general hypertensive population,
standard-therapy group (327). Post hoc whom there may be renal benets from but rather an advantage on
analysis of achieved blood pressure in long-term stricter blood pressure cardiovascular outcomes of initial
several hypertension treatment trials control) or those in whom stroke risk is a therapy with low-dose thiazide
have suggested no benet of lower concern might, as part of shared diuretics (320,336,337).
achieved SBP. As an example, among decision making, appropriately have
In people with diabetes, inhibitors of the
6,400 patients with diabetes and CAD lower systolic targets such as ,130
renin-angiotensin system (RAS) may
enrolled in one trial, tight control mmHg. This is especially true if it can be
have unique advantages for initial or
(achieved SBP ,130 mmHg) was not achieved with few drugs and without
early therapy of hypertension. In a
associated with improved cardiovascular side effects of therapy.
nonhypertension trial of high-risk
outcomes compared with usual care individuals, including a large subset with
Treatment Strategies
(achieved SBP 130140 mmHg) (328). diabetes, an ACE inhibitor reduced CVD
Although there are no well-controlled
Similar ndings emerged from an analysis outcomes (338). In patients with
studies of diet and exercise in the
of another trial. Those with SBP (,115 treatment of elevated blood pressure or congestive heart failure (CHF), including
mmHg) had increased rates of CVD hypertension in individuals with diabetic subgroups, ARBs have been
events, although they had lower rates of diabetes, the DASH study in nondiabetic shown to reduce major CVD outcomes
stroke (329). individuals has shown antihypertensive (339342), and in type 2 diabetic
Observational data, including that effects similar to pharmacological patients with signicant nephropathy,
derived from clinical trials, may be monotherapy. Lifestyle therapy consists ARBs were superior to calcium channel
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S38 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

blockers for reducing heart failure (343). conrmed adherence to optimal doses c Statin therapy should be added to
Though evidence for distinct of at least three antihypertensive agents lifestyle therapy, regardless of baseline
advantages of RAS inhibitors on CVD of different classications, one of which lipid levels, for diabetic patients:
outcomes in diabetes remains should be a diuretic, clinicians should c with overt CVD A
conicting (323,337), the high CVD consider an evaluation for secondary c without CVD who are over the age of 40
risks associated with diabetes, and the forms of hypertension. Growing years and have one or more other CVD
high prevalence of undiagnosed CVD, evidence suggests that there is an risk factors (family history of CVD,
may still favor recommendations for association between increase in sleep- hypertension, smoking, dyslipidemia,
their use as rst-line hypertension time blood pressure and incidence of or albuminuria). A
therapy in people with diabetes (320). CVD events. A recent RCT of 448
c For lower-risk patients than the above
participants with type 2 diabetes and
The blood pressure arm of the ADVANCE (e.g., without overt CVD and under the
hypertension demonstrated reduced
trial demonstrated that routine age of 40 years), statin therapy should
cardiovascular events and mortality
administration of a xed combination of be considered in addition to lifestyle
with median follow-up of 5.4 years if at
the ACE inhibitor perindopril and the therapy if LDL cholesterol remains
least one antihypertensive medication
diuretic indapamide signicantly was given at bedtime (345). above 100 mg/dL or in those with
reduced combined microvascular and multiple CVD risk factors. C
macrovascular outcomes, as well as CVD Pregnancy and Antihypertensives c In individuals without overt CVD,
and total mortality. The improved In a pregnancy complicated by diabetes the goal is LDL cholesterol ,100
outcomes could also have been due to and chronic hypertension, target blood mg/dL (2.6 mmol/L). B
lower achieved blood pressure in the pressure goals of SBP 110129 mmHg c In individuals with overt CVD, a lower
perindopril-indapamide arm (327). and DBP 6579 mmHg are reasonable, LDL cholesterol goal of ,70 mg/dL
Another trial showed a decrease in as they contribute to improved long- (1.8 mmol/L), with a high dose of a
morbidity and mortality in those receiving term maternal health. Lower blood statin, is an option. B
benazepril and amlodipine versus pressure levels may be associated with c If drug-treated patients do not reach the
benazepril and hydrochlorothiazide impaired fetal growth. During above targets on maximum tolerated
(HCTZ). The compelling benets of RAS pregnancy, treatment with ACE statin therapy, a reduction in LDL
inhibitors in diabetic patients with inhibitors and ARBs is contraindicated, cholesterol of ;3040% from baseline
albuminuria or renal insufciency since they may cause fetal damage. is an alternative therapeutic goal. B
provide additional rationale for these Antihypertensive drugs known to be c Triglyceride levels ,150 mg/dL (1.7
agents (see Section VI.B). If needed to effective and safe in pregnancy include mmol/L) and HDL cholesterol .40
achieve blood pressure targets, methyldopa, labetalol, diltiazem, mg/dL (1.0 mmol/L) in men and .50
amlodipine, HCTZ, or chlorthalidone can clonidine, and prazosin. Chronic diuretic mg/dL (1.3 mmol/L) in women are
be added. If eGFR is ,30 mL/min/m2, use during pregnancy has been desirable. C However, LDL
a loop diuretic, rather than HCTZ or associated with restricted maternal cholesteroltargeted statin therapy
chlorthalidone should be prescribed. plasma volume, which may reduce remains the preferred strategy. A
uteroplacental perfusion (346). c Combination therapy has been shown
Titration of and/or addition of further
blood pressure medications should be not to provide additional
2. Dyslipidemia/Lipid Management
made in timely fashion to overcome cardiovascular benet above statin
Recommendations
clinical inertia in achieving blood therapy alone and is not generally
Screening
recommended. A
pressure targets. c In most adult patients with diabetes, c Statin therapy is contraindicated in
Health information technology measure fasting lipid prole at least pregnancy. B
potentially can be used as a safe and annually. B
c In adults with low-risk lipid values Evidence for Benets of Lipid-
effective tool to enable attainment of
(LDL cholesterol ,100 mg/dL, HDL Lowering Therapy
blood pressure goals. Using a
cholesterol .50 mg/dL, and Patients with type 2 diabetes have an
telemonitoring intervention to direct
triglycerides ,150 mg/dL), lipid increased prevalence of lipid
titrations of antihypertensive
assessments may be repeated every 2 abnormalities, contributing to their high
medications between medical ofce
years. E risk of CVD. Multiple clinical trials have
visits has been demonstrated to have a
demonstrated signicant effects of
profound impact on SBP control (344). Treatment Recommendations and Goals pharmacological (primarily statin)
An important caveat is that most c Lifestyle modication focusing on the therapy on CVD outcomes in subjects
patients with hypertension require reduction of saturated fat, trans fat, and with CHD and for primary CVD
multiple-drug therapy to reach cholesterol intake; increase of n-3 fatty prevention (347,348). Subanalyses of
treatment goals (320). Identifying and acids, viscous ber and plant stanols/ diabetic subgroups of larger trials
addressing barriers to medication sterols; weight loss (if indicated); and (349353) and trials specically in
adherence (such as cost and side increased physical activity should be subjects with diabetes (354,355) showed
effects) should routinely be done. If recommended to improve the lipid signicant primary and secondary
blood pressure is refractory despite prole in patients with diabetes. A prevention of CVD events 1/2 CHD
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care.diabetesjournals.org Position Statement S39

deaths in diabetic patients. Meta- levels, are the most prevalent pattern of Hence, combination lipid-lowering
analyses including data from over dyslipidemia in persons with type 2 therapy cannot be broadly
18,000 patients with diabetes from diabetes. However, the evidence base recommended.
14 randomized trials of statin therapy for drugs that target these lipid fractions Dyslipidemia Treatment and Target
(mean follow-up 4.3 years), is signicantly less robust than that for Lipid Levels
demonstrate a 9% proportional statin therapy (363). Nicotinic acid has Unless they have severe
reduction in all-cause mortality, and been shown to reduce CVD outcomes hypertriglyceridemia at risk for
13% reduction in vascular mortality, (364), although the study was done in a pancreatitis, for most diabetic patients
for each mmol/L reduction in LDL nondiabetic cohort. Gembrozil has the rst priority of dyslipidemia therapy
cholesterol (356). As in those without been shown to decrease rates of CVD is to lower LDL cholesterol to ,100
diabetes, absolute reductions in hard events in subjects without diabetes mg/dL (2.60 mmol/L) (371). Lifestyle
CVD outcomes (CHD death and (365,366) and in a subgroup with diabetes intervention, including MNT, increased
nonfatal MI) are greatest in people in one of the larger trials (365). However, physical activity, weight loss, and
with high baseline CVD risk (known in a large trial specic to diabetic patients, smoking cessation, may allow some
CVD and/or very high LDL cholesterol fenobrate failed to reduce overall patients to reach lipid goals. Nutrition
levels), but the overall benets of cardiovascular outcomes (367). intervention should be tailored
statin therapy in people with diabetes according to each patients age,
at moderate or high risk for CVD are Combination Therapy diabetes type, pharmacological
convincing (357,358). Combination therapy, with a statin treatment, lipid levels, and other
and a brate or statin and niacin, may be medical conditions. Recommendations
Diabetes With Statin Use efcacious for treatment for all three
There is an increased risk of incident should focus on the reduction of
lipid fractions, but this combination is saturated fat, cholesterol, and trans
diabetes with statin use (359,360), associated with an increased risk for
which may be limited to those with unsaturated fat intake and increases in
abnormal transaminase levels, myositis, n-3 fatty acids, viscous ber (such as in
diabetes risk factors. These patients or rhabdomyolysis. The risk of
may benet additionally from diabetes oats, legumes, and citrus), and plant
rhabdomyolysis is higher with higher stanols/sterols. Glycemic control can also
screening when on statin therapy. In an doses of statins and with renal
analysis of one of the initial studies benecially modify plasma lipid levels,
insufciency and seems to be lower when particularly in patients with very high
suggesting that statins are linked to risk statins are combined with fenobrate
of diabetes, the cardiovascular event triglycerides and poor glycemic control.
than gembrozil (368). In the ACCORD
rate reduction with statins outweighed study, the combination of fenobrate and In those with clinical CVD or over age
the risk of incident diabetes even for simvastatin did not reduce the rate of fatal 40 years with other CVD risk factors,
patients at highest risk for diabetes cardiovascular events, nonfatal MI, or pharmacological treatment should be
(361). The absolute risk increase was nonfatal stroke, as compared with added to lifestyle therapy regardless of
small (over 5 years of follow-up, 1.2% of simvastatin alone, in patients with type 2 baseline lipid levels. Statins are the
participants on placebo developed diabetes who were at high risk for CVD. drugs of choice for LDL cholesterol
diabetes and 1.5% on rosuvastatin) Prespecied subgroup analyses suggested lowering and cardioprotection. In
(362). A meta-analysis of 13 randomized heterogeneity in treatment effects patients other than those described
statin trials with 91,140 participants according to sex, with a benet of above, statin treatment should be
showed an odds ratio of 1.09 for a new combination therapy for men and possible considered if there is an inadequate LDL
diagnosis of diabetes, so that (on average) harm for women, and a possible benet cholesterol response to lifestyle
treatment of 255 patients with statins for for patients with both triglyceride level modications and improved glucose
4 years resulted in one additional case $204 mg/dL and HDL cholesterol level control or if the patient has increased
of diabetes, while simultaneously #34 mg/dL (369). The AIM-HIGH trial cardiovascular risk (e.g., multiple
preventing 5.4 vascular events among randomized over 3,000 patients (about cardiovascular risk factors or long
those 255 patients (360). The relative risk- one-third with diabetes) with established diabetes duration).
benet ratio favoring statins is further CVD, low levels of HDL cholesterol, and Very little clinical trial evidence exists
supported by meta-analysis of individual triglyceride levels of 150400 mg/dL to for type 2 diabetic patients under the
data of over 170,000 persons from 27 statin therapy plus extended release age of 40 years or for type 1 diabetic
randomized trials. This demonstrated niacin or matching placebo. The trial was patients of any age. In the Heart
that individuals at low risk of vascular halted early due to lack of efcacy on the Protection Study (lower age limit 40
disease, including those undergoing primary CVD outcome (rst event of the years), the subgroup of ;600 patients
primary prevention, received benets composite of death from coronary heart with type 1 diabetes had a
from statins that included reductions in disease (CHD), nonfatal MI, ischemic proportionately similar reduction in risk
major vascular events and vascular death stroke, hospitalization for an acute to patients with type 2 diabetes,
without increase in incidence of cancer or coronary syndrome, or symptom-driven although not statistically signicant
deaths from other causes (348). coronary or cerebral revascularization) (350). Although the data are not
Low levels of HDL cholesterol, often and a possible increase in ischemic stroke denitive, similar lipid-lowering goals
associated with elevated triglyceride in those on combination therapy (370). for both type 1 and type 2 diabetic
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S40 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

patients should be considered, doses of statins fail to signicantly lower Table 10 summarizes common
particularly if they have other LDL cholesterol (,30% reduction from treatment goals for A1C, blood
cardiovascular risk factors. the patients baseline), there is no pressure, and LDL cholesterol.
Alternative Lipoprotein Goals strong evidence that combination
therapy should be used to achieve 3. Antiplatelet Agents
Most trials of statins and CVD outcome
additional LDL cholesterol lowering. Recommendations
tested specic doses of statins against
Niacin, fenobrate, ezetimibe, and bile c Consider aspirin therapy (75162 mg/
placebo or other statins, rather than
aiming for specic LDL cholesterol goals acid sequestrants all offer additional LDL day) as a primary prevention strategy in
(372). Placebo-controlled trials generally cholesterol lowering to statins alone. those with type 1 or type 2 diabetes at
achieved LDL cholesterol reductions of However, there is insufcient evidence increased cardiovascular risk (10-year
3040% from baseline. Hence, LDL that such combination therapy for LDL risk .10%). This includes most men
cholesterol lowering of this magnitude is cholesterol lowering provides a aged .50 years or women aged .60
an acceptable outcome for patients who signicant increment in CVD risk years who have at least one additional
cannot reach LDL cholesterol goals due to reduction over statin therapy alone. major risk factor (family history of CVD,
severe baseline elevations in LDL hypertension, smoking, dyslipidemia, or
cholesterol and/or intolerance of Treatment of Other Lipoprotein albuminuria). C
maximal, or any, statin doses. Fractions or Targets c Aspirin should not be recommended
Additionally for those with baseline LDL Hypertriglyceridemia should be for CVD prevention for adults with
cholesterol minimally above 100 mg/dL, addressed with dietary and lifestyle diabetes at low CVD risk (10-year CVD
prescribing statin therapy to lower LDL changes. Severe hypertriglyceridemia risk ,5%, such as in men aged ,50
cholesterol about 3040% from baseline (.1,000 mg/dL) may warrant years and women aged ,60 years
is probably more effective than immediate pharmacological therapy with no major additional CVD risk
prescribing just enough to get LDL (bric acid derivative, niacin, or sh oil) factors), since the potential adverse
cholesterol slightly below 100 mg/dL. to reduce the risk of acute pancreatitis. effects from bleeding likely offset the
If severe hypertriglyceridemia is absent, potential benets. C
Clinical trials in high-risk patients, such
then therapy targeting HDL cholesterol c In patients in these age-groups
as those with acute coronary syndromes
or triglycerides lacks the strong with multiple other risk factors (e.g.,
or previous cardiovascular events (373
evidence base of statin therapy. If the 10-year risk 510%), clinical judgment
375), have demonstrated that more
HDL cholesterol is ,40 mg/dL and the is required. E
aggressive therapy with high doses of
LDL cholesterol between 100 and 129 c Use aspirin therapy (75162 mg/day)
statins to achieve an LDL cholesterol of
mg/dL, a brate or niacin might be used, as a secondary prevention strategy in
,70 mg/dL led to a signicant reduction
especially if a patient is intolerant to those with diabetes with a history of
in further events. A reduction in LDL
statins. Niacin is the most effective drug CVD. A
cholesterol to ,70 mg/dL is an option in
for raising HDL cholesterol. It can c For patients with CVD and documented
very-high-risk diabetic patients with
signicantly increase blood glucose at aspirin allergy, clopidogrel (75 mg/day)
overt CVD (371). Some experts
high doses, but at modest doses should be used. B
recommend a greater focus on non-HDL
(7502,000 mg/day), signicant c Dual antiplatelet therapy is
cholesterol, apolipoprotein B (apoB), or
improvements in LDL cholesterol, HDL reasonable for up to a year after an
lipoprotein particle measurements to
cholesterol, and triglyceride levels are acute coronary syndrome. B
assess residual CVD risk in statin-treated
accompanied by only modest changes in
patients who are likely to have small LDL
glucose that are generally amenable to Aspirin has been shown to be effective
particles, such as people with diabetes
adjustment of diabetes therapy in reducing cardiovascular morbidity
(376), but it is unclear whether clinical
(370,379,380). and mortality in high-risk patients with
management would change with these
measurements.
In individual patients, the high variable
response seen with LDL cholesterol Table 10Summary of recommendations for glycemic, blood pressure, and lipid
lowering with statins is poorly control for most adults with diabetes
A1C ,7.0%*
understood (377). Reduction of CVD
Blood pressure ,140/80 mmHg**
events with statins correlates very
closely with LDL cholesterol lowering Lipids
LDL cholesterol ,100 mg/dL (,2.6 mmol/L)
(347). If initial attempts to prescribe a
Statin therapy for those with history of MI or age over 40
statin leads to side effects, clinicians plus other risk factors
should attempt to nd a dose or
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should
alternative statin that is tolerable. be individualized based on duration of diabetes, age/life expectancy, comorbid conditions,
There is evidence for signicant LDL known CVD or advanced microvascular complications, hypoglycemia unawareness, and
cholesterol lowering from even individual patient considerations. **Based on patient characteristics and response to therapy,
extremely low, less than daily, statin lower SBP targets may be appropriate. In individuals with overt CVD, a lower LDL cholesterol
goal of ,70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option.
doses (378). When maximally tolerated
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care.diabetesjournals.org Position Statement S41

previous MI or stroke (secondary do not have equal effects on long-term variety of ex vivo and in vitro methods
prevention). Its net benet in primary health (384). (platelet aggrenometry, measurement
prevention among patients with no In 2010, a position statement of the of thromboxane B2), these observations
previous cardiovascular events is more ADA, the American Heart Association alone are insufcient to empirically
controversial, both for patients with and (AHA), and the American College of recommend higher doses of aspirin be
without a history of diabetes (381,382). Cardiology Foundation (ACCF) used in the diabetic patient at this time.
Two RCTs of aspirin specically in recommends that low-dose (75162 A P2Y12 receptor antagonist in
patients with diabetes failed to show a mg/day) aspirin for primary prevention combination with aspirin should be used
signicant reduction in CVD end points, is reasonable for adults with diabetes for at least 1 year in patients following
raising further questions about the and no previous history of vascular an acute coronary syndrome. Evidence
efcacy of aspirin for primary supports use of either ticagrelor or
disease who are at increased CVD risk
prevention in people with diabetes clopidogrel if no percutaneous coronary
(10-year risk of CVD events over 10%) and
(190,383). intervention (PCI) was performed, and
who are not at increased risk for bleeding.
The Antithrombotic Trialists (ATT) This generally includes most men over the use of clopidogrel, ticagrelor, or
collaborators published an individual age 50 years and women over age 60 prasugrel if PCI was performed (388).
patient-level meta-analysis of the six years who also have one or more of the
large trials of aspirin for primary following major risk factors: 1) smoking, 4. Smoking Cessation
prevention in the general population. 2) hypertension, 3) dyslipidemia, 4) family Recommendations
These trials collectively enrolled over history of premature CVD, and 5) c Advise all patients not to smoke or
95,000 participants, including almost albuminuria (385). use tobacco products. A
4,000 with diabetes. Overall, they found c Include smoking cessation
However, aspirin is no longer
that aspirin reduced the risk of vascular counseling and other forms of
recommended for those at low CVD risk
events by 12% (RR 0.88 [95% CI 0.82 treatment as a routine component of
(women under age 60 years and men
0.94]). The largest reduction was for diabetes care. B
under age 50 years with no major CVD
nonfatal MI with little effect on CHD
risk factors; 10-year CVD risk under 5%)
death (RR 0.95 [95% CI 0.781.15]) or Results from epidemiological, case-
as the low benet is likely to be
total stroke. There was some evidence control, and cohort studies provide
outweighed by the risks of signicant
of a difference in aspirin effect by sex: convincing evidence to support the
aspirin signicantly reduced CVD events bleeding. Clinical judgment should be
causal link between cigarette smoking
in men, but not in women. Conversely, used for those at intermediate risk
and health risks. Much of the work
aspirin had no effect on stroke in men but (younger patients with one or more risk
documenting the effect of smoking on
signicantly reduced stroke in women. factors or older patients with no risk
health did not separately discuss results
Notably, sex differences in aspirins factors; those with 10-year CVD risk of on subsets of individuals with diabetes,
effects have not been observed in studies 510%) until further research is available. but suggests that the identied risks are
of secondary prevention (381). In the six Aspirin use in patients under the age of at least equivalent to those found in the
trials examined by the ATT collaborators, 21 years is contraindicated due to the general population. Other studies of
the effects of aspirin on major vascular associated risk of Reye syndrome. individuals with diabetes consistently
events were similar for patients with or Average daily dosages used in most demonstrate that smokers (and persons
without diabetes: RR 0.88 (95% CI 0.67 clinical trials involving patients with exposed to second-hand smoke) have a
1.15) and 0.87 (0.790.96), respectively. diabetes ranged from 50 to 650 mg but heightened risk of CVD, premature
The condence interval was wider for were mostly in the range of 100 to 325 death, and increased rate of
those with diabetes because of their mg/day. There is little evidence to microvascular complications of
smaller number. support any specic dose, but using the diabetes. Smoking may have a role in the
Based on the currently available lowest possible dosage may help reduce development of type 2 diabetes. One
evidence, aspirin appears to have a side effects (386). In the U.S., the most study in smokers with newly diagnosed
modest effect on ischemic vascular common low dose tablet is 81 mg. type 2 diabetes found that smoking
events with the absolute decrease in Although platelets from patients with cessation was associated with
events depending on the underlying diabetes have altered function, it is amelioration of metabolic parameters
CVD risk. The main adverse effects unclear what, if any, impact that nding and reduced blood pressure and
appear to be an increased risk of has on the required dose of aspirin for albuminuria at 1 year (389).
gastrointestinal bleeding. The excess cardioprotective effects in the patient The routine and thorough assessment
risk may be as high as 15 per 1,000 per with diabetes. Many alternate pathways of tobacco use is key to prevent smoking
year in real-world settings. In adults for platelet activation exist that are or encourage cessation. Numerous
with CVD risk greater than 1% per year, independent of thromboxane A2 and large randomized clinical trials
the number of CVD events prevented thus not sensitive to the effects of have demonstrated the efcacy and
will be similar to or greater than the aspirin (387). Therefore, while aspirin cost-effectiveness of brief counseling
number of episodes of bleeding resistance appears higher in the in smoking cessation, including the use
induced, although these complications diabetic patients when measured by a of quitlines, in reducing tobacco use.
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S42 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

For the patient motivated to quit, the recommended to reduce CVD events in burden have more future cardiac events
addition of pharmacological therapy to overweight or obese adults with type 2 (400402), the role of these tests
counseling is more effective than either diabetes (155). Patients at increased beyond risk stratication is not clear.
treatment alone. Special considerations CVD risk should receive aspirin and a Their routine use leads to radiation
should include assessment of level statin, and ACE inhibitor or ARB exposure and may result in unnecessary
of nicotine dependence, which is therapy if hypertensive, unless there invasive testing such as coronary
associated with difculty in quitting and are contraindications to a particular angiography and revascularization
relapse (390). Although some patients drug class. While clear benet exists procedures. The ultimate balance of
may gain weight in the period shortly for ACE inhibitor and ARB therapy in benet, cost, and risks of such an
after smoking cessation, recent research patients with nephropathy or approach in asymptomatic patients
has demonstrated that this weight gain hypertension, the benets in patients remains controversial, particularly in
does not diminish the substantial CVD with CVD in the absence of these the modern setting of aggressive CVD
risk benet realized from smoking conditions are less clear, especially risk factor control.
cessation (391). when LDL cholesterol is concomitantly A systematic review of 34,000 patients
controlled (392,393). showed that metformin is as safe as
5. Cardiovascular Disease Candidates for advanced or invasive other glucose-lowering treatments in
Recommendations cardiac testing include those with patients with diabetes and CHF, even in
Screening 1) typical or atypical cardiac symptoms those with reduced left ventricular
c In asymptomatic patients, routine and 2) an abnormal resting ECG. The ejection fraction or concomitant chronic
screening for CAD is not screening of asymptomatic patients kidney disease (CKD); however,
recommended because it does not with high CVD risk is not recommended metformin should be avoided in
improve outcomes as long as CVD risk (257), in part because these high-risk hospitalized patients (403).
factors are treated. A patients should already be receiving
Treatment
intensive medical therapy, an approach B. Nephropathy
that provides similar benet as invasive General Recommendations
c In patients with known CVD, consider
revascularization (394,395). There is c Optimize glucose control to reduce
ACE inhibitor therapy C and use
also some evidence that silent MI may the risk or slow the progression of
aspirin and statin therapy A (if not
reverse over time, adding to the nephropathy. A
contraindicated) to reduce the risk of
controversy concerning aggressive c Optimize blood pressure control to
cardiovascular events.
screening strategies (396). Finally, a reduce the risk or slow the
c In patients with a prior MI, b-blockers
recent randomized observational trial progression of nephropathy. A
should be continued for at least 2
demonstrated no clinical benet to
years after the event. B Screening
routine screening of asymptomatic
c In patients with symptomatic heart
patients with type 2 diabetes and c Perform an annual test to quantitate
failure, avoid thiazolidinedione urine albumin excretion in type 1
normal ECGs (397). Despite abnormal
treatment. C diabetic patients with diabetes
myocardial perfusion imaging in more
c In patients with stable CHF,
than one in ve patients, cardiac duration of $5 years and in all type 2
metformin may be used if renal diabetic patients starting at
outcomes were essentially equal (and
function is normal but should be diagnosis. B
very low) in screened versus unscreened
avoided in unstable or hospitalized
patients. Accordingly, the overall Treatment
patients with CHF. B
effectiveness, especially the cost- c An ACE inhibitor or ARB for the
In all patients with diabetes, effectiveness, of such an indiscriminate primary prevention of diabetic kidney
cardiovascular risk factors should be screening strategy is now questioned. disease is not recommended in
assessed at least annually. These risk Despite the intuitive appeal, recent diabetic patients with normal blood
factors include dyslipidemia, studies have found that a risk factor pressure and albumin excretion ,30
hypertension, smoking, a positive family based approach to the initial diagnostic mg/24 h. B
history of premature coronary disease, evaluation and subsequent follow-up c Either ACE inhibitors or ARBs (but not
and the presence of albuminuria. for CAD fails to identify which patients both in combination) are
Abnormal risk factors should be treated with type 2 diabetes will have silent recommended for the treatment of
as described elsewhere in these ischemia on screening tests (398,399). the nonpregnant patient with
guidelines. Intensive lifestyle The effectiveness of newer noninvasive modestly elevated (30299 mg/24 h)
intervention focusing on weight loss CAD screening methods, such as C or higher levels (.300 mg/24 h) of
through decreased caloric intake and computed tomography (CT) and CT urinary albumin excretion. A
increased physical activity as performed angiography, to identify patient c For people with diabetes and diabetic
in the Look AHEAD trial may be subgroups for different treatment kidney disease (albuminuria .30 mg/
considered for improving glucose strategies remains unproven. Although 24 h), reducing the amount of dietary
control, tness, and some CVD risk asymptomatic diabetic patients found protein below usual intake is not
factors. However, it is not to have a higher coronary disease recommended because it does not
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care.diabetesjournals.org Position Statement S43

alter glycemic measures, A number of interventions have been renin-angiotensin-aldosterone system


cardiovascular risk measures, or the demonstrated to reduce the risk and (e.g., an ACE inhibitor plus an ARB, a
course of GFR decline. A slow the progression of renal disease. mineralocorticoid antagonist, or a direct
c When ACE inhibitors, ARBs, or Intensive diabetes management renin inhibitor) provide additional
diuretics are used, monitor serum with the goal of achieving near- lowering of albuminuria (424427).
creatinine and potassium levels for normoglycemia has been shown in large However, such combinations have been
the development of increased prospective randomized studies to found to provide no additional
creatinine or changes in potassium. E delay the onset and progression of cardiovascular benet and have higher
c Continued monitoring of urine increased urinary albumin excretion in adverse event rates (428). At least one
albumin excretion to assess both patients with type 1 (413) and type 2 randomized clinical trial has shown an
response to therapy and (85,86,89,90) diabetes. The UKPDS increase in adverse events, particularly
progression of disease is provided strong evidence that blood impaired kidney function and
reasonable. E pressure control can reduce the hyperkalemia, compared with either
c When eGFR is ,60 mL/min/1.73 m2, development of nephropathy (323). In agent alone, despite a reduction in
evaluate and manage potential addition, large prospective randomized albuminuria using combination therapy
complications of CKD. E studies in patients with type 1 diabetes (410).
c Consider referral to a physician have demonstrated that achievement Diuretics, calcium channel blockers, and
experienced in the care of kidney of lower levels of SBP (,140 mmHg) b-blockers should be used as additional
disease for uncertainty about the resulting from treatment using ACE therapy to further lower blood pressure
etiology of kidney disease, difcult inhibitors provides a selective benet in patients already treated with ACE
management issues, or advanced over other antihypertensive drug inhibitors or ARBs (343) or as alternate
kidney disease. B classes in delaying the progression of therapy in the rare individual unable to
increased urinary albumin excretion tolerate ACE inhibitors or ARBs.
To be consistent with newer and can slow the decline in GFR in
patients with higher levels of Studies in patients with varying stages of
nomenclature intended to emphasize nephropathy have shown that protein
the continuous nature of albuminuria albuminuria (414,415). In type 2
diabetes with hypertension and restriction of dietary protein helps slow
as a risk factor, the terms the progression of albuminuria, GFR
microalbuminuria (30299 mg/24 h) normoalbuminuria, RAS inhibition has
been demonstrated to delay onset of decline, and occurrence of ESRD (429
and macroalbuminuria (.300 432), although more recent studies have
elevated albuminuria (416,417). In the
mg/24 h) will no longer be used, but provided conicting results (157).
latter study, there was an unexpected
rather referred to as persistent Dietary protein restriction might be
higher rate of fatal cardiovascular
albuminuria at levels 30299 mg/24 h considered particularly in patients
events with olmesartan among patients
and levels $300 mg/24 h. Normal whose nephropathy seems to be
with preexisting CHD.
albumin excretion is currently dened progressing despite optimal glucose and
as ,30 mg/24 h. ACE inhibitors have been shown to blood pressure control and use of ACE
reduce major CVD outcomes (i.e., MI, inhibitor and/or ARBs (432).
Diabetic nephropathy occurs in 2040% stroke, death) in patients with diabetes
of patients with diabetes and is the (338), thus further supporting the use of Assessment of Albuminuria Status and
single leading cause of ESRD. Persistent these agents in patients with elevated Renal Function
albuminuria in the range of 30299 mg/ albuminuria, a CVD risk factor. ARBs do Screening for increased urinary albumin
24 h has been shown to be an early stage not prevent onset of elevated excretion can be performed by
of diabetic nephropathy in type 1 albuminuria in normotensive patients measurement of the albumin-to-
diabetes and a marker for development with type 1 or type 2 diabetes (418,419); creatinine ratio in a random spot
of nephropathy in type 2 diabetes. It is a however, ARBs have been shown to collection; 24-h or timed collections are
well-established marker of increased reduce the progression rate of albumin more burdensome and add little to
CVD risk (404406). However, there is levels from 30 to 299 mg/24 h to levels prediction or accuracy (433,434).
increasing evidence of spontaneous $300 mg/24 h as well as ESRD in Measurement of a spot urine for
remission of albumin levels 30299 mg/ patients with type 2 diabetes (420422). albumin alone (whether by
24 h in up to 40% of patients with type 1 Some evidence suggests that ARBs have a immunoassay or by using a dipstick test
diabetes. About 3040% remain with smaller magnitude of rise in potassium specic for albuminuria) without
30299 mg/24 h and do not progress to compared with ACE inhibitors in people simultaneously measuring urine
more elevated levels of albuminuria with nephropathy (423). creatinine is less expensive but
($300 mg/24 h) over 510 years of In the absence of side effects or adverse susceptible to false-negative and
follow-up (407410). Patients with events (e.g., hyperkalemia or acute -positive determinations as a result of
persistent albuminuria (30299 mg/24 h) kidney injury), it is suggested to titrate variation in urine concentration due to
who progress to more signicant levels up to the maximum approved dose for hydration and other factors.
($300 mg/24 h are likely to progress to the treatment of hypertension. Abnormalities of albumin excretion and
ESRD (411,412). Combinations of drugs that block the the linkage between albumin-to-creatinine
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S44 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

ratio and 24-h albumin excretion Table 12Stages of chronic kidney disease
are dened in Table 11. Because of GFR (mL/min/1.73 m2 body
variability in urinary albumin Stage Description surface area)
excretion, two of three specimens
1 Kidney damage* with normal or increased GFR $90
collected within a 3- to 6-month period
2 Kidney damage* with mildly decreased GFR 6089
should be abnormal before considering a
3 Moderately decreased GFR 3059
patient to have developed increased
4 Severely decreased GFR 1529
urinary albumin excretion or had a
progression in albuminuria. Exercise 5 Kidney failure ,15 or dialysis
within 24 h, infection, fever, CHF, *Kidney damage dened as abnormalities on pathologic, urine, blood, or imaging tests. Adapted
marked hyperglycemia, and marked from Levey et al. (434).
hypertension may elevate urinary
albumin excretion over baseline
values. CKD-EPI equation. GFR calculators are advanced kidney disease. The threshold
available at http://www.nkdep.nih.gov. for referral may vary depending on the
Information on presence of abnormal frequency with which a provider
urine albumin excretion in addition to The role of continued annual
quantitative assessment of albumin encounters diabetic patients with
level of GFR may be used to stage CKD. signicant kidney disease. Consultation
The National Kidney Foundation excretion after diagnosis of albuminuria
and institution of ACE inhibitor or ARB with a nephrologist when stage 4 CKD
classication (Table 12) is primarily develops has been found to reduce cost,
based on GFR levels and may be therapy and blood pressure control is
unclear. Continued surveillance can improve quality of care, and keep
superseded by other systems in which people off dialysis longer (438).
staging includes other variables such as assess both response to therapy and
progression of disease. Some suggest However, nonrenal specialists should
urinary albumin excretion (435). not delay educating their patients about
Studies have found decreased GFR in that reducing albuminuria to the normal
(,30 mg/g) or near-normal range may the progressive nature of diabetic
the absence of increased urine albumin kidney disease, the renal preservation
excretion in a substantial percentage improve renal and cardiovascular
prognosis, but this approach has not benets of aggressive treatment of
of adults with diabetes (436). blood pressure, blood glucose, and
Substantial evidence shows that in been formally evaluated in prospective
trials, and more recent evidence hyperlipidemia, and the potential need
patients with type 1 diabetes and for renal transplant.
persistent albumin levels 30299 reported spontaneous remission of
mg/24 h, screening with albumin albuminuria in up to 40% of type 1
diabetic patients. C. Retinopathy
excretion rate alone would miss .20%
General Recommendations
of progressive disease (410). Serum Conversely, patients with increasing
creatinine with estimated GFR should albumin levels, declining GFR, increasing c Optimize glycemic control to reduce
therefore be assessed at least annually blood pressure, retinopathy, the risk or slow the progression of
in all adults with diabetes, regardless macrovascular disease, elevated lipids retinopathy. A
of the degree of urine albumin and/or uric acid concentrations, or c Optimize blood pressure control to
excretion. a family history of CKD are more likely to reduce the risk or slow the
experience a progression of diabetic progression of retinopathy. A
Serum creatinine should be used to
estimate GFR and to stage the level of kidney disease (410). Screening
CKD, if present. eGFR is commonly Complications of kidney disease c Adults with type 1 diabetes should
coreported by laboratories or can be correlate with level of kidney function. have an initial dilated and
estimated using formulae such as the When the eGFR is ,60 mL/min/1.73 m2, comprehensive eye examination by
Modication of Diet in Renal Disease screening for complications of CKD is an ophthalmologist or optometrist
(MDRD) study equation (437) or the indicated (Table 13). Early vaccination within 5 years after the onset of
against HBV is indicated in patients likely diabetes. B
to progress to end-stage kidney disease. c Patients with type 2 diabetes should
Table 11Denitions of Consider referral to a physician have an initial dilated and
abnormalities in albumin excretion experienced in the care of kidney comprehensive eye examination by
Spot collection disease when there is uncertainty about an ophthalmologist or optometrist
Category (mg/mg creatinine) the etiology of kidney disease (heavy shortly after the diagnosis of
Normal ,30 proteinuria, active urine sediment, diabetes. B
Increased urinary $30 absence of retinopathy, rapid decline in c If there is no evidence of retinopathy
albumin excretion* GFR, and resistant hypertension). Other for one or more eye exams, then
*Historically, ratios between 30 and 299 triggers for referral may include difcult exams every 2 years may be
have been called microalbuminuria and management issues (anemia, secondary considered. If diabetic retinopathy is
those 300 or greater have been called hyperparathyroidism, metabolic bone present, subsequent examinations
macroalbuminuria (or clinical albuminuria).
disease, or electrolyte disturbance) or for type 1 and type 2 diabetic patients
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care.diabetesjournals.org Position Statement S45

Table 13Management of CKD in diabetes although tight targets (systolic ,120


GFR Recommended
mmHg) do not impart additional benet
(442). Several case series and a
All patients Yearly measurement of creatinine, urinary albumin excretion, potassium
controlled prospective study suggest
4560 Referral to a nephrologist if possibility for nondiabetic kidney disease exists
that pregnancy in type 1 diabetic
(duration of type 1 diabetes ,10 years, heavy proteinuria, abnormal
ndings on renal ultrasound, resistant hypertension, rapid fall in GFR, or patients may aggravate retinopathy
active urinary sediment on ultrasound) (443,444). Laser photocoagulation
Consider need for dose adjustment of medications surgery can minimize this risk (444).
Monitor eGFR every 6 months
One of the main motivations for
Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus,
parathyroid hormone at least yearly screening for diabetic retinopathy is the
Assure vitamin D sufciency long-established efcacy of laser
Consider bone density testing photocoagulation surgery in preventing
Referral for dietary counseling visual loss. Two large trials, the Diabetic
3044 Monitor eGFR every 3 months Retinopathy Study (DRS) in patients
Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid with PDR and the Early Treatment
hormone, hemoglobin, albumin, weight every 36 months
Diabetic Retinopathy Study (ETDRS) in
Consider need for dose adjustment of medications
patients with macular edema, provide
,30 Referral to a nephrologist
the strongest support for the
Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes. therapeutic benets of
photocoagulation surgery. The DRS
(445) showed that panretinal
should be repeated annually by an loss in patients with high-risk PDR, photocoagulation surgery reduced the
ophthalmologist or optometrist. If clinically signicant macular edema, risk of severe vision loss from PDR from
retinopathy is progressing or sight and in some cases severe NPDR. A 15.9% in untreated eyes to 6.4% in
threatening, then examinations will c Anti-vascular endothelial growth treated eyes, with greatest risk-benet
be required more frequently. B factor (VEGF) therapy is indicated for ratio in those with baseline disease (disc
c High-quality fundus photographs can diabetic macular edema. A neovascularization or vitreous
detect most clinically signicant c The presence of retinopathy is not a hemorrhage).
diabetic retinopathy. Interpretation contraindication to aspirin therapy
of the images should be performed for cardioprotection, as this therapy The ETDRS (446) established the benet
by a trained eye care provider. While does not increase the risk of retinal of focal laser photocoagulation surgery
retinal photography may serve as a hemorrhage. A in eyes with macular edema, particularly
screening tool for retinopathy, it is those with clinically signicant macular
not a substitute for a comprehensive Diabetic retinopathy is a highly specic edema, with reduction of doubling of
eye exam, which should be vascular complication of both type 1 and the visual angle (e.g., 20/50 to 20/100)
performed at least initially and at type 2 diabetes, with prevalence from 20% in untreated eyes to 8%
intervals thereafter as recommended strongly related to the duration of in treated eyes. The ETDRS also
by an eye care professional. E diabetes. Diabetic retinopathy is the veried the benets of panretinal
c Women with preexisting diabetes most frequent cause of new cases of photocoagulation for high-risk PDR and
who are planning pregnancy or who blindness among adults aged 2074 in older-onset patients with severe
have become pregnant should have a years. Glaucoma, cataracts, and other NPDR or less-than-high-risk PDR.
comprehensive eye examination disorders of the eye occur earlier and Laser photocoagulation surgery in both
and be counseled on the risk of more frequently in people with trials was benecial in reducing the risk
development and/or progression diabetes. of further visual loss, but generally not
of diabetic retinopathy. Eye benecial in reversing already
In addition to duration of diabetes,
examination should occur in the rst diminished acuity. Recombinant
factors that increase the risk of, or are
trimester with close follow-up monoclonal neutralizing antibody to
associated with, retinopathy include
throughout pregnancy and for 1 year VEGF improves vision and reduces the
chronic hyperglycemia (439),
postpartum. B need for laser photocoagulation in
nephropathy (440), and hypertension
Treatment (441). Intensive diabetes management patients with macular edema (447).
with the goal of achieving near- Other emerging therapies for
c Promptly refer patients with any level
of macular edema, severe NPDR, or normoglycemia has been shown in large retinopathy include sustained
any PDR to an ophthalmologist who is prospective randomized studies to intravitreal delivery of uocinolone
knowledgeable and experienced in prevent and/or delay the onset and (448) and the possibility of prevention
the management and treatment of progression of diabetic retinopathy with fenobrate (449,450).
diabetic retinopathy. A (76,85,86,442). Lowering blood The preventive effects of therapy and
c Laser photocoagulation therapy is pressure has been shown to decrease the fact that patients with PDR or
indicated to reduce the risk of vision the progression of retinopathy (323), macular edema may be asymptomatic
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S46 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

provide strong support for a screening diagnosis of type 1 diabetes and at Effective symptomatic treatments are
program to detect diabetic least annually thereafter, using available for the neuropathic pain of
retinopathy. Because retinopathy is simple clinical tests. B DPN such as neuropathic pain (455)
estimated to take at least 5 years to c Electrophysiological testing or and for limited symptoms of
develop after the onset of referral to a neurologist is rarely autonomic neuropathy.
hyperglycemia, patients with type 1 needed, except in situations Diagnosis of Neuropathy
diabetes should have an initial dilated where the clinical features are Distal Symmetric Polyneuropathy. Patients
and comprehensive eye examination atypical. E with diabetes should be screened
within 5 years after the diabetes (451). c Screening for signs and symptoms of annually for DPN symptoms using
Patients with type 2 diabetes, who CAN should be instituted at diagnosis simple clinical tests. Symptoms vary
may have had years of undiagnosed of type 2 diabetes and 5 years after according to the class of sensory bers
diabetes and who have a signicant the diagnosis of type 1 diabetes. involved. The most common symptoms
risk of prevalent diabetic retinopathy Special testing is rarely needed and are induced by the involvement of small
at time of diagnosis should have an may not affect management or bers and include pain, dysesthesias
initial dilated and comprehensive eye outcomes. E (unpleasant abnormal sensations of
examination. Examinations should be c Medications for the relief of specic burning and tingling associated with
performed by an ophthalmologist or symptoms related to painful DPN and peripheral nerve lesions), and
optometrist who is knowledgeable autonomic neuropathy are numbness. Clinical tests include
and experienced in diagnosing recommended because they may assessment of vibration threshold
diabetic retinopathy. Subsequent
reduce pain B and improve quality of using a 128-Hz tuning fork, pinprick
examinations for type 1 and type 2
life. E sensation and light touch perception
diabetic patients are generally
using a 10-g monolament, and ankle
repeated annually. Exams every 2 years
The diabetic neuropathies are reexes. Assessment should follow the
may be cost-effective after one or
heterogeneous with diverse clinical typical DPN pattern, starting distally
more normal eye exams, and in a
manifestations. They may be focal or (the dorsal aspect of the hallux) on both
population with well-controlled type 2
diffuse. The most prevalent sides and move proximally until
diabetes there was essentially no risk
neuropathies are chronic sensorimotor threshold is detected. Several clinical
of development of signicant
DPN and autonomic neuropathy. instruments that combine more than
retinopathy with a 3-year interval
Although DPN is a diagnosis of one test have .87% sensitivity in
after a normal examination (452).
exclusion, complex investigations or detecting DPN (83,456,457).
Examinations will be required more
frequently if retinopathy is referral for neurology consultation to In patients with severe or atypical
progressing. exclude other conditions is rarely neuropathy, causes other than diabetes
needed. should always be considered, such as
Retinal photography, with remote
The early recognition and appropriate neurotoxic medications, heavy metal
reading by experts, has great potential
management of neuropathy in the poisoning, alcohol abuse, vitamin B12
in areas where qualied eye care
patient with diabetes is important for a deciency (especially in those taking
professionals are not available. It may
number of reasons: metformin for prolonged periods) (458),
also enhance efciency and reduce costs
renal disease, chronic inammatory
when the expertise of ophthalmologists
1. Nondiabetic neuropathies may be demyelinating neuropathy, inherited
can be used for more complex
present in patients with diabetes and neuropathies, and vasculitis (459).
examinations and for therapy (453). In-
person exams are still necessary when may be treatable. Diabetic Autonomic Neuropathy. The
the photos are unacceptable and for 2. A number of treatment options exist symptoms and signs of autonomic
follow-up of abnormalities detected. for symptomatic diabetic dysfunction should be elicited carefully
Photos are not a substitute for a neuropathy. during the history and physical
comprehensive eye exam, which should 3. Up to 50% of DPN may be examination. Major clinical
be performed at least initially and at asymptomatic and patients are at manifestations of diabetic autonomic
intervals thereafter as recommended by risk for insensate injury to their feet. neuropathy include resting tachycardia,
an eye care professional. Results of eye 4. Autonomic neuropathy and exercise intolerance, orthostatic
examinations should be documented particularly CAN is an independent hypotension, constipation,
and transmitted to the referring health risk factor for cardiovascular gastroparesis, erectile dysfunction,
care professional. mortality (261,454). sudomotor dysfunction, impaired
neurovascular function, and,
D. Neuropathy Specic treatment for the underlying potentially, autonomic failure in
Recommendations nerve damage is currently not response to hypoglycemia.
c All patients should be screened for available, other than improved
distal symmetric polyneuropathy glycemic control, which may modestly Cardiovascular Autonomic Neuropathy.
(DPN) starting at diagnosis of type 2 slow progression in type 2 diabetes CAN is the most studied and clinically
diabetes and 5 years after the (90) but not reverse neuronal loss. important form of diabetic autonomic
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care.diabetesjournals.org Position Statement S47

neuropathy because of its association patients with type 1 diabetes for many require the use of both pharmacological
with mortality risk independent of years (461464). While the evidence is and nonpharmacological measures
other cardiovascular risk factors not as strong for type 2 diabetes as for (e.g., avoiding medications that
(261,397). In early stages CAN may be type 1 diabetes, some studies have aggravate hypotension, using
completely asymptomatic and detected demonstrated a modest slowing of compressive garments over the legs and
by changes in heart rate variability and progression (90,465) without reversal of abdomen).
abnormal cardiovascular reex tests neuronal loss. Several observational Gastroparesis Symptoms. Gastroparesis
(R-R response to deep breathing, studies further suggest that neuropathic symptoms may improve with dietary
standing and Valsalva maneuver). symptoms improve not only with changes and prokinetic agents such as
Advanced disease may be indicated by optimization of control but also with the erythromycin. Recently, the European
resting tachycardia (.100 bpm) and avoidance of extreme blood glucose Medicines Agency (www.ema.europa.
orthostasis (a fall in SBP .20 mmHg or uctuations. eu/docs/en_GB/document_library/
DBP of at least 10 mmHg upon standing Distal Symmetric Polyneuropathy. DPN Press_release/2013/07/WC500146614.
without an appropriate heart rate symptoms, and especially neuropathic pdf) decided that risks of extrapyramidal
response). The standard cardiovascular pain, can be severe, have sudden onset, symptoms with metoclopramide
reex testing, especially the deep- and are associated with lower quality of outweigh benets. In Europe,
breathing test, is noninvasive, easy to life, limited mobility, depression, and metoclopramide use is now restricted
perform, reliable, and reproducible and social dysfunction (466). There is limited to a maximum use of 5 days and is no
has prognostic value. Although some clinical evidence regarding the most longer indicated for the long-term
societies have developed guidelines for effective treatments for individual treatment of gastroparesis. Although the
screening for CAN, the benets of patient needs given the wide range of FDA decision is pending, it is suggested
sophisticated testing beyond risk available medications (467,468). Two that metoclopramide be reserved to only
stratication are not clear (460). drugs have been approved for relief of the most severe cases that are
Gastrointestinal Neuropathies. DPN pain in the U.S.dpregabalin and unresponsive to other therapies. Side
Gastrointestinal neuropathies (e.g., duloxetinedbut neither of these effects should be closely monitored.
esophageal enteropathy, gastroparesis, affords complete relief, even when used Erectile Dysfunction.Treatments for
constipation, diarrhea, fecal in combination. Venlafaxine, erectile dysfunction may include
incontinence) may involve any section amitriptyline, gabapentin, valproate, phosphodiesterase type 5 inhibitors,
of the gastrointestinal tract. Gastroparesis opioids (morphine sulfate, tramadol, intracorporeal or intraurethral
should be suspected in individuals with and oxycodone controlled-release) may prostaglandins, vacuum devices, or
erratic glucose control or with upper also be effective and could be penile prostheses. Interventions for
gastrointestinal symptoms without other considered for treatment of painful other manifestations of autonomic
identied cause. Evaluation of solid-phase DPN. Head-to-head treatment neuropathy are described in the ADA
gastric emptying using double-isotope comparisons and studies that include statement on neuropathy (468). As with
scintigraphy may be done if symptoms are quality-of-life outcomes are rare, so DPN treatments, these interventions do
suggestive, but test results often correlate treatment decisions must often follow a not change the underlying pathology
poorly with symptoms. Constipation is trial-and-error approach. Given the and natural history of the disease
the most common lower-gastrointestinal range of partially effective treatment process, but may have a positive impact
symptom but can alternate with episodes options, a tailored and step-wise on the quality of life of the patient.
of diarrhea. pharmacological strategy with careful
Genitourinary Tract Disturbances. attention to relative symptom
E. Foot Care
Diabetic autonomic neuropathy is also improvement, medication adherence,
Recommendations
associated with genitourinary tract and medication side effects is
c For all patients with diabetes,
disturbances. In men, diabetic recommended to achieve pain reduction
and improve quality of life (455). perform an annual comprehensive
autonomic neuropathy may cause foot examination to identify risk
erectile dysfunction and/or retrograde Autonomic Neuropathy. An intensive factors predictive of ulcers and
ejaculation. Evaluation of bladder multifactorial cardiovascular risk amputations. The foot examination
dysfunction should be performed for intervention targeting glucose, blood should include inspection,
individuals with diabetes who have pressure, lipids, smoking, and other assessment of foot pulses, and testing
recurrent urinary tract infections, lifestyle factors has been shown to reduce for loss of protective sensation (LOPS)
pyelonephritis, incontinence, or a the progression and development of CAN (10-g monolament plus testing any
palpable bladder. among patients with type 2 diabetes one of the following: vibration using
Treatment (469). 128-Hz tuning fork, pinprick
Glycemic Control. Tight and stable Orthostatic Hypotension. Treatment of sensation, ankle reexes, or vibration
glycemic control, implemented as early orthostatic hypotension is challenging. perception threshold). B
as possible has been shown to The therapeutic goal is to minimize c Provide general foot self-care
effectively prevent the development of postural symptoms rather than to education to all patients with
DPN and autonomic neuropathy in restore normotension. Most patients diabetes. B
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S48 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

c A multidisciplinary approach is examination to identify high-risk (e.g., smoking, hypertension,


recommended for individuals with conditions at least annually. Clinicians hyperlipidemia, or duration of diabetes
foot ulcers and high-risk feet, should ask about history of previous .10 years). Refer patients with
especially those with a history of prior foot ulceration or amputation, signicant symptoms or a positive ABI
ulcer or amputation. B neuropathic or peripheral vascular for further vascular assessment and
c Refer patients who smoke, have LOPS symptoms, impaired vision, tobacco consider exercise, medications, and
and structural abnormalities, or have use, and foot care practices. A general surgical options (471).
history of prior lower-extremity inspection of skin integrity and
complications to foot care specialists musculoskeletal deformities should be Patient Education
for ongoing preventive care and done in a well-lit room. Vascular Patients with diabetes and high-risk foot
lifelong surveillance. C assessment would include inspection conditions should be educated
c Initial screening for peripheral and assessment of pedal pulses. regarding their risk factors and
arterial disease (PAD) should appropriate management. Patients at
The neurological exam recommended is
include a history for claudication and risk should understand the implications
designed to identify LOPS rather than
an assessment of the pedal pulses. of LOPS, the importance of foot
early neuropathy. The clinical
Consider obtaining an ankle-brachial monitoring on a daily basis, the proper
examination to identify LOPS is simple
index (ABI), as many patients with care of the foot, including nail and skin
and requires no expensive equipment.
PAD are asymptomatic. C care, and the selection of appropriate
Five simple clinical tests (use of a 10-g
c Refer patients with signicant footwear. Patients with LOPS should be
monolament, vibration testing using a
claudication or a positive ABI for educated on ways to substitute other
128-Hz tuning fork, tests of pinprick
further vascular assessment and sensory modalities (hand palpation,
sensation, ankle reex assessment, and
consider exercise, medications, and visual inspection) for surveillance of
testing vibration perception threshold
surgical options. C early foot problems. Patients
with a biothesiometer), each with
understanding of these issues and their
evidence from well-conducted
Amputation and foot ulceration, physical ability to conduct proper foot
prospective clinical cohort studies, are
consequences of diabetic neuropathy surveillance and care should be
considered useful in the diagnosis of
and/or PAD, are common and are major assessed. Patients with visual
LOPS in the diabetic foot. The task force
causes of morbidity and disability in difculties, physical constraints
agreed that any of the ve tests listed
people with diabetes. Loss of 10-g preventing movement, or cognitive
could be used by clinicians to identify
monolament perception and reduced problems that impair their ability to
LOPS, although ideally two of these
vibration perception predict foot assess the condition of the foot and to
should be regularly performed during
ulcers (468). Early recognition and institute appropriate responses will
the screening examdnormally the 10-g
management of risk factors can prevent need other people, such as family
monolament and one other test. One
or delay adverse outcomes. members, to assist in their care.
or more abnormal tests would suggest
The risk of ulcers or amputations is LOPS, while at least two normal tests Treatment
increased in people who have the (and no abnormal test) would rule out People with neuropathy or evidence of
following risk factors: LOPS. The last test listed, vibration increased plantar pressure (e.g.,
assessment using a biothesiometer or erythema, warmth, callus, or measured
c Previous amputation similar instrument, is widely used in the pressure) may be adequately managed
c Past foot ulcer history U.S.; however, identication of the with well-tted walking shoes or athletic
c Peripheral neuropathy patient with LOPS can easily be carried shoes that cushion the feet and
c Foot deformity out without this or other expensive redistribute pressure. Callus can be
c Peripheral vascular disease equipment. debrided with a scalpel by a foot care
c Visual impairment
Screening
specialist or other health professional
c Diabetic nephropathy (especially
Initial screening for PAD should with experience and training in foot
patients on dialysis)
include a history for claudication and an care. People with bony deformities (e.g.,
c Poor glycemic control
assessment of the pedal pulses. A hammertoes, prominent metatarsal
c Cigarette smoking
diagnostic ABI should be performed in heads, bunions) may need extra-wide
In 2008, ADA published screening any patient with symptoms of PAD. Due or -deep shoes. People with extreme
recommendations (470). Clinicians are to the high estimated prevalence of PAD bony deformities (e.g., Charcot foot)
encouraged to review this report for in patients with diabetes and the fact who cannot be accommodated with
further details and practical descriptions that many patients with PAD are commercial therapeutic footwear may
of how to perform components of the asymptomatic, an ADA consensus need custom-molded shoes.
comprehensive foot examination. statement on PAD (471) suggested Most diabetic foot infections are
that a screening ABI be performed in polymicrobial, with aerobic gram-
Examination patients over 50 years of age and be positive cocci (GPC), and especially
All adults with diabetes should considered in patients under 50 years of staphylococci, the most common
undergo a comprehensive foot age who have other PAD risk factors causative organisms.
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care.diabetesjournals.org Position Statement S49

Wounds without evidence of soft tissue in men and women (478). The fracture, although fracture risk was
or bone infection do not require prevalence in general populations with higher in diabetic participants
antibiotic therapy. type 2 diabetes may be up to 23% (479) compared with participants without
Empiric antibiotic therapy can be and in obese participants enrolled in the diabetes for a given T score and age or
narrowly targeted at GPC in many Look AHEAD trial exceeded 80% (480). for a given FRAX score risk (489). It is
acutely infected patients, but those at Treatment of sleep apnea signicantly appropriate to assess fracture history
risk for infection with antibiotic- improves quality of life and blood and risk factors in older patients with
resistant organisms or with chronic, pressure control. The evidence for a diabetes and recommend BMD testing if
previously treated, or severe infections treatment effect on glycemic control is appropriate for the patients age and
require broader spectrum regimens and mixed (481). sex. Prevention strategies are the same
should be referred to specialized care as for the general population. For type 2
Fatty Liver Disease diabetic patients with fracture risk
centers (472). Foot ulcers and wound Unexplained elevations of hepatic
care may require care by a podiatrist, factors, avoiding use of
transaminase concentrations are thiazolidinediones is warranted.
orthopedic or vascular surgeon, or signicantly associated with higher BMI,
rehabilitation specialist experienced in waist circumference, triglycerides, and Cognitive Impairment
the management of individuals with fasting insulin, and with lower HDL Diabetes is associated with signicantly
diabetes. Guidelines for treatment of cholesterol. In a prospective analysis, increased risk and rate of cognitive
diabetic foot ulcers have recently been diabetes was signicantly associated decline and increased risk of dementia
updated (472). with incident nonalcoholic chronic liver (490,491). In a 15-year prospective
disease and with hepatocellular study of community-dwelling people
VII. ASSESSMENT OF COMMON carcinoma (482). Interventions that over the age of 60 years, the presence of
COMORBID CONDITIONS improve metabolic abnormalities in diabetes at baseline signicantly
Recommendation patients with diabetes (weight loss, increased the age- and sex-adjusted
glycemic control, treatment with incidence of all-cause dementia,
c Consider assessing for and addressing
specic drugs for hyperglycemia or Alzheimer disease, and vascular
common comorbid conditions that
dyslipidemia) are also benecial for dementia compared with rates in those
may complicate the management of
fatty liver disease (483). with normal glucose tolerance (492).
diabetes. B
In a substudy of the ACCORD study,
Cancer there were no differences in cognitive
Improved disease prevention and
Diabetes (possibly only type 2 diabetes) outcomes between intensive and
treatment efcacy means that patients
is associated with increased risk of standard glycemic control, although
with diabetes are living longer, often
cancers of the liver, pancreas, there was signicantly less of a
with multiple comorbidities requiring
endometrium, colon/rectum, breast, decrement in total brain volume by MRI
complicated medical regimens (473). In
and bladder (484). The association may in participants in the intensive arm
addition to the commonly appreciated
result from shared risk factors between (493). The effects of hyperglycemia and
comorbidities of obesity, hypertension,
type 2 diabetes and cancer (obesity, age, insulin on the brain are areas of intense
and dyslipidemia, diabetes
physical inactivity) but may also be due research interest.
management is often complicated by
to hyperinsulinemia or hyperglycemia Low Testosterone in Men
concurrent conditions such as heart
(485,486). Patients with diabetes Mean levels of testosterone are lower in
failure, depression and anxiety, arthritis,
should be encouraged to undergo men with diabetes compared with age-
and other diseases or conditions at rates
recommended age- and sex-appropriate matched men without diabetes, but
higher than those of age-matched
cancer screenings and to reduce their obesity is a major confounder (494).
people without diabetes. These
modiable cancer risk factors (obesity, Treatment in asymptomatic men is
concurrent conditions present clinical
smoking, physical inactivity). controversial. The evidence for effects
challenges related to polypharmacy,
prevalent symptoms, and complexity of Fractures
of testosterone replacement on
care (474477). Age-matched hip fracture risk is outcomes is mixed, and recent
signicantly increased in both type 1 guidelines suggest that screening and
Depression treatment of men without symptoms
(summary RR 6.3) and type 2 diabetes
As discussed in Section V.H, depression, are not recommended (495).
(summary RR 1.7) in both sexes (487).
anxiety, and other mental health
Type 1 diabetes is associated with Periodontal Disease
symptoms are highly prevalent in
osteoporosis, but in type 2 diabetes Periodontal disease is more severe, but
people with diabetes and are associated
an increased risk of hip fracture is not necessarily more prevalent, in
with worse outcomes.
seen despite higher bone mineral patients with diabetes than in those
Obstructive Sleep Apnea density (BMD) (488). In three large without (496). Current evidence
Age-adjusted rates of obstructive sleep observational studies of older adults, suggests that periodontal disease
apnea, a risk factor for CVD, are femoral neck BMD T score and the WHO adversely affects diabetes outcomes,
signicantly higher (4- to 10-fold) with Fracture Risk Algorithm (FRAX) score although evidence for treatment
obesity, especially with central obesity, were associated with hip and nonspine benets is currently lacking (477).
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S50 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Hearing Impairment and family. The balance between adult lower A1C should be balanced against
Hearing impairment, both high supervision and self-care should be the risks of hypoglycemia and the
frequency and low/mid frequency, is dened at the rst interaction and re- developmental burdens of intensive
more common in people with diabetes, evaluated at each clinic visit. This regimens in children and youth. Age-
perhaps due to neuropathy and/or relationship will evolve as the child specic glycemic and A1C goals are
vascular disease. In NHANES analysis, reaches physical, psychological, and presented in Table 14.
hearing impairment was about twice as emotional maturity.
great in people with diabetes compared b. Screening and Management of
a. Glycemic Control Complications
with those without, after adjusting for
Recommendation
age and other risk factors for hearing i. Nephropathy
impairment (497). c Consider age when setting glycemic
Recommendations
goals in children and adolescents with
Screening
type 1 diabetes. E
VIII. DIABETES CARE IN SPECIFIC c Annual screening for albumin levels,
POPULATIONS Current standards for diabetes with a random spot urine sample for
A. Children and Adolescents management reect the need to lower albumin-to-creatinine ratio (ACR),
1. Type 1 Diabetes glucose as safely possible. This should should be considered for the child at
Three-quarters of all cases of type 1 be done with step-wise goals. Special the start of puberty or at age $10
diabetes are diagnosed in individuals consideration should be given to the years, whichever is earlier, once the
,18 years of age. The provider must unique risks of hypoglycemia in young youth has had diabetes for 5 years. B
consider the unique aspects of care children. For young children (,7 years Treatment
and management of children and old), glycemic goals may need to be
c Treatment with an ACE inhibitor,
adolescents with type 1 diabetes, such modied since most at that age have a
titrated to normalization of albumin
as changes in insulin sensitivity related form of hypoglycemic unawareness,
excretion, should be considered
to sexual maturity and physical growth, including immaturity of and a relative
when elevated ACR is subsequently
ability to provide self-care, supervision inability to recognize and respond to
conrmed on two additional
in child care and school, and unique hypoglycemic symptoms. This places
specimens from different days. This
neurological vulnerability to them at greater risk for severe
should be obtained over a 6-month
hypoglycemia and DKA. Attention to hypoglycemia. While it was previously
interval following efforts to improve
family dynamics, developmental stages, thought that young children were at risk
glycemic control and normalize blood
and physiological differences related to for cognitive impairment after episodes
pressure for age. E
sexual maturity are all essential in of severe hypoglycemia, current data
developing and implementing an have not conrmed this (295,499,500). Recent research demonstrates the
optimal diabetes regimen. Due to the Furthermore, new therapeutic importance of good glycemic and blood
paucity of clinical research in children, modalities, such as rapid and long-acting pressue control, especially as diabetes
the recommendations for children and insulin analogs, technological advances duration increases (506).
adolescents are less likely to be based (e.g., low glucose suspend), and
on clinical trial evidence. However, education may mitigate the incidence ii. Hypertension
expert opinion and a review of available of severe hypoglycemia (501). In
Recommendations
and relevant experimental data are adolescents, the DCCT demonstrated
Screening
summarized in the ADA statement on that near-normalization of blood glucose
c Blood pressure should be measured at
care of children and adolescents with levels was more difcult to achieve
type 1 diabetes (498). compared with adults. Nevertheless, the each routine visit. Children found to have
increased frequency of basal-bolus high-normal blood pressure or
The care of a child or adolescent with hypertension should have blood pressure
type 1 diabetes should be provided by a regimens and insulin pumps in youth
from infancy through adolescence has conrmed on a separate day. B
multidisciplinary team of specialists
trained in pediatric diabetes been associated with more children Treatment
management. At the very least, reaching ADA blood glucose targets c Initial treatment of high-normal
education of the child and family should (502504) in those families in which blood pressure (SBP or DBP
be provided by health care providers both parents and the child with diabetes consistently above the 90th
trained and experienced in childhood participate jointly to perform the percentile for age, sex, and height)
diabetes and sensitive to the challenges required diabetes-related tasks. includes dietary intervention and
posed by diabetes in this age-group. It is Furthermore, studies documenting exercise, aimed at weight control
essential that DSME, MNT, and neurocognitive imaging differences of and increased physical activity, if
psychosocial support be provided at hyperglycemia in children provide appropriate. If target blood pressure
diagnosis and regularly thereafter by another compelling motivation for is not reached with 36 months
individuals experienced with the achieving glycemic targets (505). of lifestyle intervention,
educational, nutritional, behavioral, and In selecting glycemic goals, the long- pharmacological treatment should
emotional needs of the growing child term health benets of achieving a be considered. E
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care.diabetesjournals.org Position Statement S51

Table 14Plasma blood glucose and A1C goals for type 1 diabetes by age-group
Plasma blood glucose goal range
(mg/dL)
Values by age (years) Before meals Bedtime/overnight A1C Rationale
Toddlers and preschoolers (06) 100180 110200 ,8.5% c Vulnerability to hypoglycemia
c Insulin sensitivity
c Unpredictability in dietary intake and physical activity
c A lower goal (,8.0%) is reasonable if it can be achieved
without excessive hypoglycemia
School age (612) 90180 100180 ,8% c Vulnerability of hypoglycemia
c A lower goal (,7.5%) is reasonable if it can be achieved
without excessive hypoglycemia
Adolescents and young adults (1319) 90130 90150 ,7.5% c A lower goal (,7.0%) is reasonable if it can be achieved
without excessive hypoglycemia
Key concepts in setting glycemic goals:
c Goals should be individualized and lower goals may be reasonable based on benet-risk assessment.
c Blood glucose goals should be modied in children with frequent hypoglycemia or hypoglycemia unawareness.
c Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and
to help assess glycemia in those on basal-bolus regimens.

c Pharmacological treatment of cardiovascular event before age 55 Children diagnosed with type 1 diabetes
hypertension (SBP or DBP years, or if family history is unknown, have a high risk of early subclinical
consistently above the 95th then consider obtaining a fasting lipid (507,508) and clinical (509) CVD.
percentile for age, sex, and height or prole in children .2 years of age soon Although intervention data are lacking,
consistently .130/80 mmHg, if 95% after the diagnosis (after glucose the AHA categorizes children with type 1
exceeds that value) should be control has been established). If family diabetes in the highest tier for
considered as soon as the diagnosis is history is not of concern, then consider cardiovascular risk and recommends
conrmed. E the rst lipid screening at puberty ($10 both lifestyle and pharmacological
c ACE inhibitors should be considered years). For children diagnosed with treatment for those with elevated LDL
for the initial pharmacological diabetes at or after puberty, consider cholesterol levels (510,511). Initial
treatment of hypertension, following obtaining a fasting lipid prole soon therapy should be with a Step 2 AHA
appropriate reproductive counseling after the diagnosis (after glucose diet, which restricts saturated fat to 7%
due to its potential teratogenic control has been established). E of total calories and restricts dietary
effects. E c For both age-groups, if lipids are cholesterol to 200 mg/day. Data from
c The goal of treatment is blood abnormal, annual monitoring is randomized clinical trials in children as
pressure consistently ,130/80 or reasonable. If LDL cholesterol values young as 7 months of age indicate that
below the 90th percentile for are within the accepted risk levels this diet is safe and does not interfere
age, sex, and height, whichever is (,100 mg/dL [2.6 mmol/L]), a lipid with normal growth and development
lower. E prole repeated every 5 years is (512,513). Abnormal results from a
reasonable. E random lipid panel should be conrmed
Blood pressure measurements should with a fasting lipid panel. Evidence has
Treatment
be determined correctly, using the shown that improved glucose control
c Initial therapy may consist of correlates with a more favorable lipid
appropriate size cuff, and with the child
seated and relaxed. Hypertension optimization of glucose control and prole. However, improved glycemic
should be conrmed on at least three MNT using a Step 2 AHA diet aimed control alone will not reverse signicant
separate days. Normal blood pressure at a decrease in the amount of dyslipidemia (514). Neither long-term
levels for age, sex, and height saturated fat in the diet. E safety nor cardiovascular outcome
c After the age of 10 years, the addition efcacy of statin therapy has been
and appropriate methods for
determinations are available online at of a statin in patients who, after MNT established for children. However,
www.nhlbi.nih.gov/health/prof/heart/ and lifestyle changes, have LDL studies have shown short-term safety
hbp/hbp_ped.pdf. cholesterol .160 mg/dL (4.1 mmol/L) equivalent to that seen in adults and
or LDL cholesterol .130 mg/dL (3.4 efcacy in lowering LDL cholesterol
iii. Dyslipidemia mmol/L) and one or more CVD risk levels, improving endothelial function
Recommendations factors is reasonable. E and causing regression of carotid
Screening c The goal of therapy is an LDL intimal thickening (515517). Statins
c If there is a family history of cholesterol value ,100 mg/dL are not approved for use under the age
hypercholesterolemia or a (2.6 mmol/L). E of 10 years, and statin treatment
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S52 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

should generally not be used in disease in asymptomatic children with vi. Hypothyroidism
children with type 1 diabetes prior positive antibodies. E Recommendations
to this age. For postpubertal girls, c Children with biopsy-conrmed
c Consider screening children with type
issues of pregnancy prevention are celiac disease should be placed on a
1 diabetes for antithyroid peroxidase
paramount, since statins are category X gluten-free diet and have
and antithyroglobulin antibodies
in pregnancy (see Section VIII.B for consultation with a dietitian
soon after diagnosis. E
more information). experienced in managing both
c Measuring thyroid-stimulating
iv. Retinopathy diabetes and celiac disease. B
hormone (TSH) concentrations soon
Recommendations after diagnosis of type 1 diabetes,
c An initial dilated and comprehensive Celiac disease is an immune-mediated after metabolic control has been
eye examination should be disorder that occurs with increased established, is reasonable. If normal,
frequency in patients with type 1 consider rechecking every 12 years,
considered for the child at the start of
diabetes (116% of individuals especially if the patient develops
puberty or at age $10 years,
compared with 0.31% in the general symptoms of thyroid dysfunction,
whichever is earlier, once the youth
population) (519,520). Symptoms of thyromegaly, an abnormal growth
has had diabetes for 35 years. B
celiac disease include diarrhea, weight rate, or unusual glycemic variation. E
c After the initial examination, annual
routine follow-up is generally loss or poor weight gain, growth
failure, abdominal pain, chronic Autoimmune thyroid disease is the most
recommended. Less frequent
fatigue, malnutrition due to common autoimmune disorder
examinations may be acceptable on
malabsorption, and other associated with diabetes, occurring in
the advice of an eye care
gastrointestinal problems, and 1730% of patients with type 1 diabetes
professional. E
unexplained hypoglycemia or erratic (524). About one-quarter of type 1
blood glucose concentrations. diabetic children have thyroid
Although retinopathy (like albuminuria)
autoantibodies at the time of diagnosis
most commonly occurs after the onset
Screening (525), and the presence of thyroid
of puberty and after 510 years of
Screening for celiac disease includes autoantibodies is predictive of thyroid
diabetes duration (518), it has been
measuring serum levels of tissue dysfunction, generally hypothyroidism
reported in prepubertal children and
transglutaminase or antiendomysial but less commonly hyperthyroidism
with diabetes duration of only 12 antibodies, then small-bowel biopsy in (526). Subclinical hypothyroidism may
years. Referrals should be made to eye antibody-positive children. European be associated with increased risk of
care professionals with expertise in guidelines on screening for celiac disease symptomatic hypoglycemia (527) and
diabetic retinopathy, an understanding in children (not specic to children with with reduced linear growth (528).
of retinopathy risk in the pediatric type 1 diabetes) suggested that biopsy Hyperthyroidism alters glucose
population, and experience in may not be necessary in symptomatic metabolism, potentially resulting in
counseling the pediatric patient and children with positive antibodies, as long deterioration of metabolic control.
family on the importance of early as further testing such as genetic or HLA
prevention/intervention. c. Self-Management
testing was supportive, but that
v. Celiac Disease asymptomatic at-risk children should No matter how sound the medical
have biopsies (521). One small study that regimen, it can only be as good as the
Recommendations
included children with and without type 1 ability of the family and/or individual to
c Consider screening children with type implement it. Family involvement
diabetes suggested that antibody-
1 diabetes for celiac disease by remains an important component of
positive but biopsy-negative children
measuring IgA antitissue optimal diabetes management
were similar clinically to those who were
transglutaminase or antiendomysial throughout childhood and adolescence.
biopsy-positive.
antibodies, with documentation of Health care providers who care for
normal total serum IgA levels, soon Treatment children and adolescents, therefore,
after the diagnosis of diabetes. E Biopsy-negative children had benets must be capable of evaluating the
c Testing should be considered in from a gluten-free diet, but worsening educational, behavioral, emotional, and
children with a positive family history on a usual diet (522). This was a small psychosocial factors that impact
of celiac disease, growth failure, study, and children with type 1 diabetes implementation of a treatment plan and
failure to gain weight, weight loss, already follow a careful diet. However, it must work with the individual and
diarrhea, atulence, abdominal pain, is difcult to advocate for not family to overcome barriers or redene
or signs of malabsorption or in conrming the diagnosis by biopsy goals as appropriate.
children with frequent unexplained before recommending a lifelong gluten-
hypoglycemia or deterioration in free diet, especially in asymptomatic d. School and Day Care
glycemic control. E children. In symptomatic children with Since a large portion of a childs day is
c Consider referral to a gastroenterologist type 1 diabetes and celiac disease, spent in school, close communication
for evaluation with possible endoscopy gluten-free diets reduce symptoms and with and cooperation of school or day
and biopsy for conrmation of celiac rates of hypoglycemia (523). care personnel is essential for optimal
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care.diabetesjournals.org Position Statement S53

diabetes management, safety, and specic recommendations, is found (32) provides guidance on the
maximal academic opportunities. See in the ADA position statement prevention, screening, and treatment of
the ADA position statement Diabetes Diabetes Care for Emerging Adults: type 2 diabetes and its comorbidities in
Care in the School and Day Care Setting Recommendations for Transition From young people.
(529) for further discussion. Pediatric to Adult Diabetes Care 3. Monogenic Diabetes Syndromes
e. Transition From Pediatric to Adult Systems (532). Monogenic forms of diabetes
Care The National Diabetes Education (neonatal diabetes or maturity-onset
Recommendations Program (NDEP) has materials available diabetes of the young) represent a
c As teens transition into emerging to facilitate the transition process small fraction of children with diabetes
adulthood, health care providers (http://ndep.nih.gov/transitions/), and (,5%), but readily available
and families must recognize their The Endocrine Society in collaboration commercial genetic testing now
many vulnerabilities B and with ADA and other organizations has enables a true genetic diagnosis with
prepare the developing teen, developed transition tools for clinicians increasing frequency. It is important
beginning in early to mid and youth/families (http://www.endo- to correctly diagnose one of the
adolescence and at least 1 year prior society.org/clinicalpractice/ monogenic forms of diabetes, as these
to the transition. E transition_of_care.cfm). children may be incorrectly diagnosed
c Both pediatricians and adult health 2. Type 2 Diabetes
with type 1 or type 2 diabetes, leading
care providers should assist in The CDC recently published projections to suboptimal treatment regimens and
providing support and links to for type 2 diabetes prevalence using the delays in diagnosing other family
resources for the teen and emerging SEARCH database. Assuming a 2.3% members.
adult. B annual increase, the prevalence of type The diagnosis of monogenic diabetes
2 diabetes in those under 20 years of age should be considered in children with
Care and close supervision of diabetes will quadruple in 40 years (31,38). Given the following situations:
management is increasingly shifted the current obesity epidemic,
from parents and other older adults distinguishing between type 1 and type c Diabetes diagnosed within the rst six
throughout childhood and adolescence; 2 diabetes in children can be difcult. months of life.
however, the shift from pediatrics to Autoantigens and ketosis may be c Strong family history of diabetes but
adult health care providers often occurs present in a substantial number of without typical features of type 2
very abruptly as the older teen enters patients with features of type 2 diabetes diabetes (nonobese, low-risk ethnic
the next developmental stage referred (including obesity and acanthosis group).
to as emerging adulthood (530), nigricans). Such a distinction at c Mild fasting hyperglycemia (100150
a critical period for young people who diagnosis is critical since treatment mg/dL [5.58.5 mmol]), especially if
have diabetes. During this period of regimens, educational approaches, young and nonobese.
major life transitions, youth begin to dietary counsel, and outcomes will c Diabetes but with negative auto-
move out of their parents home and differ markedly between the two antibodies without signs of obesity or
must become more fully responsible for diagnoses. insulin resistance.
their diabetes care including the many Type 2 diabetes has a signicant
aspects of self-management, making A recent international consensus
incidence of comorbidities already
medical appointments, and nancing present at the time of diagnosis (535). It
document discusses in further detail the
health care once they are no longer diagnosis and management of children
is recommended that blood pressure
covered under their parents health with monogenic forms of diabetes
measurement, a fasting lipid prole,
insurance (531,532). In addition to (536).
assessment for albumin excretion, and
lapses in health care, this is also a period dilated eye examination be performed
of deterioration in glycemic control, at diagnosis. Thereafter, screening B. Preconception Care
increased occurrence of acute guidelines and treatment Recommendations
complications, psycho-social- recommendations for hypertension, c A1C levels should be as close to
emotional-behavioral issues, and dyslipidemia, albumin excretion, and normal as possible (,7%) in an
emergence of chronic complications retinopathy in youth with type 2 individual patient before conception
(531534). diabetes are similar to those for youth is attempted. B
Though scientic evidence continues to with type 1 diabetes. Additional c Starting at puberty, preconception
be limited, it is clear that early and problems that may need to be counseling should be incorporated in
ongoing attention be given to addressed include polycystic ovarian the routine diabetes clinic visit for all
comprehensive and coordinated disease and the various comorbidities women of childbearing potential. B
planning for seamless transition of all associated with pediatric obesity such as c Women with diabetes who are
youth from pediatric to adult health sleep apnea, hepatic steatosis, contemplating pregnancy should be
care (531,532). A comprehensive orthopedic complications, and evaluated and, if indicated, treated for
discussion regarding the challenges psychosocial concerns. The ADA diabetic retinopathy, nephropathy,
faced during this period, including consensus statement on this subject neuropathy, and CVD. B
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S54 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

c Medications used by such women participated in preconception care absolutely contraindicated during
should be evaluated prior to (range 1.01.7% of infants) was much pregnancy. Statins are category X
conception, since drugs commonly lower than the incidence in women who (contraindicated for use in pregnancy)
used to treat diabetes and its did not participate (range 1.410.9% of and should be discontinued before
complications may be infants) (104). One limitation of these conception, as should ACE inhibitors
contraindicated or not recommended studies is that participation in (539). ARBs are category C (risk cannot
in pregnancy, including statins, ACE preconception care was self-selected be ruled out) in the rst trimester but
inhibitors, ARBs, and most noninsulin rather than randomized. Thus, it is category D (positive evidence of risk) in
therapies. E impossible to be certain that the lower later pregnancy and should generally be
c Since many pregnancies are malformation rates resulted fully from discontinued before pregnancy. Since
unplanned, consider the potential improved diabetes care. Nonetheless, many pregnancies are unplanned,
risks and benets of medications that the evidence supports the concept that health care professionals caring for any
are contraindicated in pregnancy in malformations can be reduced or woman of childbearing potential should
all women of childbearing potential prevented by careful management of consider the potential risks and benets
and counsel women using such diabetes before pregnancy (537). of medications that are contraindicated
medications accordingly. E in pregnancy. Women using
Planned pregnancies greatly facilitate
preconception diabetes care. medications such as statins or ACE
Major congenital malformations remain inhibitors need ongoing family planning
the leading cause of mortality and Unfortunately, nearly two-thirds of
pregnancies in women with diabetes are counseling. Among the oral antidiabetic
serious morbidity in infants of mothers agents, metformin and acarbose are
with type 1 and type 2 diabetes. unplanned, potentially leading to
malformations in infants of diabetic classied as category B (no evidence of
Observational studies indicate that the risk in humans) and all others as
risk of malformations increases mothers. To minimize the occurrence of
these devastating malformations, category C. Potential risks and benets
continuously with increasing maternal of oral antidiabetic agents in the
glycemia during the rst 68 weeks of beginning at the onset of puberty or at
diagnosis, all women with diabetes with preconception period must be carefully
gestation, as dened by rst-trimester weighed, recognizing that data are
A1C concentrations. There is no childbearing potential should receive
1) education about the risk of insufcient to establish the safety of
threshold for A1C values below which these agents in pregnancy.
risk disappears entirely. However, malformations associated with
malformation rates above the 12% unplanned pregnancies and poor For further discussion of preconception
background rate of nondiabetic metabolic control and 2) use of effective care, see the ADA consensus statement
pregnancies appear to be limited to contraception at all times, unless the on preexisting diabetes and pregnancy
pregnancies in which rst-trimester A1C patient has good metabolic control and (104) and the position statement (540).
concentrations are .1% above the is actively trying to conceive. A recent
study showed that preconception C. Older Adults
normal range for a nondiabetic
pregnant woman. counseling using simple educational Recommendations
tools enabled adolescent girls to make c Older adults who are functional,
Preconception Care well-informed decisions lasting up to 9 cognitively intact, and have
Preconception care of diabetes appears months (538). signicant life expectancy should
to reduce the risk of congenital Women contemplating pregnancy need receive diabetes care with goals
malformations. Five nonrandomized to be seen frequently by a similar to those developed for
studies compared rates of major multidisciplinary team experienced in younger adults. E
malformations in infants between diabetes management both before and c Glycemic goals for some older adults
women who participated in during pregnancy. The goals of might reasonably be relaxed, using
preconception diabetes care programs preconception care are to 1) involve and individual criteria, but hyperglycemia
and women who initiated intensive empower the patient on diabetes leading to symptoms or risk of acute
diabetes management after they were management, 2) achieve the lowest A1C hyperglycemic complications should
already pregnant. The preconception test results possible without excessive be avoided in all patients. E
care programs were multidisciplinary hypoglycemia, 3) assure effective c Other cardiovascular risk factors
and designed to train patients in contraception until stable and should be treated in older adults with
diabetes self-management with diet, acceptable glycemia is achieved, and 4) consideration of the time frame of
intensied insulin therapy, and SMBG. identify, evaluate, and treat long-term benet and the individual patient.
Goals were set to achieve normal blood diabetes complications such as Treatment of hypertension is
glucose concentrations, and .80% of retinopathy, nephropathy, neuropathy, indicated in virtually all older adults,
subjects achieved normal A1C hypertension, and CHD (104). and lipid and aspirin therapy may
concentrations before they became benet those with life expectancy at
pregnant. In all ve studies, the Drugs Contraindicated in Pregnancy least equal to the time frame of
incidence of major congenital Drugs commonly used in the diabetes primary or secondary prevention
malformations in women who treatment may be relatively or trials. E
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care.diabetesjournals.org Position Statement S55

c Screening for diabetes complications adults with diabetes is complicated by expected to live long enough to reap the
should be individualized in older their clinical and functional benets of long-term intensive diabetes
adults, but particular attention heterogeneity. Some older individuals management, who have good cognitive
should be paid to complications developed diabetes years earlier and and functional function, and who choose
that would lead to functional may have signicant complications; to do so via shared decision making may
impairment. E others who are newly diagnosed may be treated using therapeutic
have had years of undiagnosed diabetes interventions and goals similar to those
Diabetes is an important health with resultant complications or may for younger adults with diabetes. As with
condition for the aging population; at have truly recent-onset disease and few all patients, DSME and ongoing DSMS are
least 20% of patients over the age of 65 or no complications. Some older adults vital components of diabetes care for
years have diabetes, and this number with diabetes are frail and have other older adults and their caregivers.
can be expected to grow rapidly in the underlying chronic conditions, For patients with advanced diabetes
coming decades. Older individuals with substantial diabetes-related complications, life-limiting comorbid
diabetes have higher rates of premature comorbidity, or limited physical or illness, or substantial cognitive or
death, functional disability, and cognitive functioning. Other older functional impairment, it is reasonable
coexisting illnesses such as individuals with diabetes have little to set less intensive glycemic target
hypertension, CHD, and stroke than comorbidity and are active. Life goals. These patients are less likely to
those without diabetes. Older adults expectancies are highly variable for this benet from reducing the risk of
with diabetes are also at greater risk population, but often longer than microvascular complications and more
than other older adults for several clinicians realize. Providers caring for likely to suffer serious adverse effects
common geriatric syndromes, such as older adults with diabetes must take this from hypoglycemia. However, patients
polypharmacy, depression, cognitive heterogeneity into consideration when with poorly controlled diabetes may be
impairment, urinary incontinence, setting and prioritizing treatment goals subject to acute complications of
injurious falls, and persistent pain. (Table 15). diabetes, including dehydration, poor
A consensus report on diabetes There are few long-term studies in older wound healing, and hyperglycemic
and older adults (541) inuenced adults demonstrating the benets of hyperosmolar coma. Glycemic goals at a
the following discussion and intensive glycemic, blood pressure, and minimum should avoid these
recommendations. The care of older lipid control. Patients who can be consequences.

Table 15Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults
with diabetes
Fasting or Bedtime Blood
Patient characteristics/ Reasonable preprandial glucose pressure
health status Rationale A1C goal glucose (mg/dL) (mg/dL) (mmHg) Lipids
Healthy (few coexisting Longer remaining life ,7.5% 90130 90150 ,140/80 Statin unless
chronic illnesses, intact expectancy contraindicated or not
cognitive and functional tolerated
status)
Complex/intermediate Intermediate remaining ,8.0% 90150 100180 ,140/80 Statin unless
(multiple coexisting life expectancy, high contraindicated or not
chronic illnesses* or 21 treatment burden, tolerated
instrumental ADL hypoglycemia
impairments or mild-to- vulnerability, fall risk
moderate cognitive
impairment)
Very complex/poor health Limited remaining life ,8.5% 100180 110200 ,150/90 Consider likelihood of
(long-term care or end- expectancy makes benet with statin
stage chronic illnesses** benet uncertain (secondary prevention
or moderate-to-severe more so than primary)
cognitive impairment or
21 ADL dependencies)
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes.
The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient/
caregiver preferences is an important aspect of treatment individualization. Additionally, a patients health status and preferences may change over
time. ADL, activities of daily living. A lower goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue
treatment burden. *Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include
arthritis, cancer, CHF, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, MI, and stroke. By multiple, we mean at least
three, but many patients may have ve or more (132). **The presence of a single end-stage chronic illness such as stage 3-4 CHF or oxygen-
dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer may cause signicant symptoms or impairment of functional
status and signicantly reduce life expectancy. A1C of 8.5% equates to an eAG of ;200 mg/dL. Looser glycemic targets than this may expose
patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.
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S56 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Although hyperglycemia control may be c Annual monitoring for complications treatment of persistent
important in older individuals with of diabetes is recommended, hyperglycemia starting at a
diabetes, greater reductions in morbidity beginning 5 years after the diagnosis threshold of no greater than 180
and mortality may result from control of of CFRD. E mg/dL (10 mmol/L). Once insulin
other cardiovascular risk factors rather than therapy is started, a glucose range
from tight glycemic control alone. There is CFRD is the most common comorbidity of 140180 mg/dL (7.810 mmol/L)
strong evidence from clinical trials of the in persons with cystic brosis, occurring is recommended for the majority of
value of treating hypertension in the elderly in about 20% of adolescents and 40 critically ill patients. A
(542,543). There is less evidence for lipid- 50% of adults. Diabetes in this  More stringent goals, such as 110
lowering and aspirin therapy, although the population is associated with worse 140 mg/dL (6.17.8 mmol/L) may
benets of these interventions for primary nutritional status, more severe be appropriate for selected
and secondary prevention are likely to inammatory lung disease, and greater patients, as long as this can be
apply to older adults whose life mortality from respiratory failure. achieved without signicant
expectancies equal or exceed the time Insulin insufciency related to partial hypoglycemia. C
frames seen in clinical trials. brotic destruction of the islet mass is  Critically ill patients require an
the primary defect in CFRD. Genetically intravenous insulin protocol that
Special care is required in prescribing determined function of the remaining has demonstrated efcacy and
and monitoring pharmacological b-cells and insulin resistance associated safety in achieving the desired
therapy in older adults. Costs may be a with infection and inammation may glucose range without increasing
signicant factor, especially since also play a role. Encouraging data risk for severe hypoglycemia. E
older adults tend to be on many suggest that improved screening  Noncritically ill patients: There is
medications. Metformin may be (544,545) and aggressive insulin therapy no clear evidence for specic
contraindicated because of renal have narrowed the gap in mortality blood glucose goals. If treated
insufciency or signicant heart failure. between cystic brosis patients with with insulin, the premeal blood
Thiazolidinediones, if used at all, should and without diabetes, and have glucose targets generally ,140
be used very cautiously in those with, or eliminated the sex difference in mg/dL (7.8 mmol/L) with random
at risk for, CHF, and have also been mortality (546). Recent trials comparing blood glucose ,180 mg/dL (10.0
associated with fractures. Sulfonylureas, insulin with oral repaglinide showed no mmol/L) are reasonable,
other insulin secretagogues, and insulin signicant difference between the provided these targets can be
can cause hypoglycemia. Insulin use groups. Insulin remains the most widely safely achieved. More stringent
requires that patients or caregivers have used therapy for CFRD (547). targets may be appropriate in
good visual and motor skills and
Recommendations for the clinical stable patients with previous
cognitive ability. DPP-4 inhibitors have
management of CFRD can be found in tight glycemic control. Less
few side effects, but their costs may be a
the recent ADA position statement on stringent targets may be
barrier to some older patients; the latter
this topic (548). appropriate in those with severe
is also the case for GLP-1 agonists.
comorbidities. E
Screening for diabetes complications in  Scheduled subcutaneous insulin
older adults also should be IX. DIABETES CARE IN SPECIFIC
with basal, nutritional, and
SETTINGS
individualized. Particular attention correctional components is the
should be paid to complications that can A. Diabetes Care in the Hospital preferred method for achieving
develop over short periods of time and/ Recommendations and maintaining glucose control in
or that would signicantly impair c Diabetes discharge planning should noncritically ill patients. C
functional status, such as visual and start at hospital admission, and clear  Glucose monitoring should be
lower-extremity complications. diabetes management instructions initiated in any patient not known
should be provided at discharge. E to be diabetic who receives
D. Cystic FibrosisRelated Diabetes c The sole use of sliding scale insulin in therapy associated with high risk
Recommendations the inpatient hospital setting is for hyperglycemia, including
c Annual screening for CFRD with OGTT discouraged. E high-dose glucocorticoid
should begin by age 10 years in all c All patients with diabetes admitted to therapy, initiation of enteral or
patients with cystic brosis who do not the hospital should have their parenteral nutrition, or other
have CFRD. B A1C as a screening test diabetes clearly identied in the medications such as octreotide or
for CFRD is not recommended. B medical record. E immunosuppressive medications. B
c During a period of stable health, the c All patients with diabetes should have If hyperglycemia is documented
diagnosis of CFRD can be made in an order for blood glucose monitoring, and persistent, consider treating
cystic brosis patients according to with results available to all members of such patients to the same glycemic
usual glucose criteria. E the health care team. E goals as in patients with known
c Patients with CFRD should be treated c Goals for blood glucose levels: diabetes. E
with insulin to attain individualized  Critically ill patients: Insulin  A hypoglycemia management
glycemic goals. A therapy should be initiated for protocol should be adopted and
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care.diabetesjournals.org Position Statement S57

implemented by each hospital or diabetes) to poor outcomes. Cohort ,140 mg/dL and that a highly stringent
hospital system. A plan for studies as well as a few early RCTs target of ,110 mg/dL may actually be
preventing and treating suggested that intensive treatment of dangerous.
hypoglycemia should be hyperglycemia improved hospital In a meta-analysis of 26 trials (N 5
established for each patient. outcomes (549551). In general, these 13,567), which included the NICE-
Episodes of hypoglycemia in the studies were heterogeneous in terms of SUGAR data, the pooled RR of death
hospital should be documented in patient population, blood glucose with intensive insulin therapy was 0.93
the medical record and tracked. E targets and insulin protocols used, as compared with conventional therapy
 Consider obtaining an A1C in provision of nutritional support and the (95% CI 0.831.04) (557). Approximately
patients with diabetes admitted to proportion of patients receiving insulin, half of these trials reported
the hospital if the result of testing which limits the ability to make hypoglycemia, with a pooled RR of
in the previous 23 months is not meaningful comparisons among them. intensive therapy of 6.0 (95% CI 4.5
available. E Trials in critically ill patients have failed 8.0). The specic ICU setting inuenced
 Consider obtaining an A1C in to show a signicant improvement in the ndings, with patients in surgical
patients with risk factors for mortality with intensive glycemic ICUs appearing to benet from intensive
undiagnosed diabetes who exhibit control (552,553) or have even shown insulin therapy (RR 0.63 [95% CI 0.44
hyperglycemia in the hospital. E increased mortality risk (554). 0.91]), while those in other medical and
 Patients with hyperglycemia in the Moreover, these recent RCTs have mixed critical care settings did not. It
hospital who do not have a prior highlighted the risk of severe was concluded that, overall, intensive
diagnosis of diabetes should have hypoglycemia resulting from such insulin therapy increased the risk of
appropriate plans for follow-up efforts (552557). hypoglycemia but provided no overall
testing and care documented at The largest study to date, NICE- benet on mortality in the critically ill,
discharge. E SUGAR, a multicenter, multinational although a possible mortality benet to
RCT, compared the effect of intensive patients admitted to the surgical ICU
Hyperglycemia in the hospital can
glycemic control (target 81108 mg/dL, was suggested.
represent previously known diabetes,
mean blood glucose attained
previously undiagnosed diabetes, or 1. Glycemic Targets in Hospitalized
115 mg/dL) to standard glycemic
hospital-related hyperglycemia (fasting Patients
control (target 144180 mg/dL, mean
blood glucose $126 mg/dL or random
blood glucose attained 144 mg/dL) on Denition of Glucose Abnormalities in
blood glucose $200 mg/dL occurring
outcomes among 6,104 critically ill the Hospital Setting
during the hospitalization that reverts to Hyperglycemia in the hospital has been
participants, almost all of whom
normal after hospital discharge). The required mechanical ventilation (554). dened as any blood glucose .140 mg/
difculty distinguishing between the Ninety-day mortality was signicantly dL (7.8 mmol/L). Levels that are
second and third categories during the higher in the intensive versus the signicantly and persistently above this
hospitalization may be overcome by conventional group in both surgical and may require treatment in hospitalized
measuring an A1C in undiagnosed medical patients, as was mortality from patients. A1C values .6.5% suggest, in
patients with hyperglycemia, as long as cardiovascular causes. Severe undiagnosed patients, that diabetes
conditions interfering with A1C utility hypoglycemia was also more common preceded hospitalization (558).
(hemolysis, blood transfusion) have not in the intensively treated group (6.8% Hypoglycemia has been dened as any
occurred. Hyperglycemia management vs. 0.5%; P , 0.001). The precise reason blood glucose ,70 mg/dL (3.9 mmol/L).
in the hospital has been considered for the increased mortality in the This is the standard denition in
secondary in importance to the tightly controlled group is unknown. outpatients and correlates with the
condition that prompted admission. The study results lie in stark contrast initial threshold for the release of
However, a body of literature now to a 2001 single-center study that counter-regulatory hormones. Severe
supports targeted glucose control in the reported a 42% relative reduction hypoglycemia in hospitalized patients
hospital setting for potential improved in intensive care unit (ICU) mortality in has been dened by many as ,40 mg/
clinical outcomes. Hyperglycemia in the critically ill surgical patients treated dL (2.2 mmol/L), although this is lower
hospital may result from stress, to a target blood glucose of 80110 mg/dL than the ;50 mg/dL (2.8 mmol/L) level
decompensation of type 1 or type 2 or (549). Importantly, the control group in at which cognitive impairment begins in
other forms of diabetes, and/or may be NICE-SUGAR had reasonably good blood normal individuals (559). Both hyper-
iatrogenic due to withholding of glucose management, maintained at a and hypoglycemia among inpatients are
antihyperglycemic medications or mean glucose of 144 mg/dL, only associated with adverse short- and
administration of hyperglycemia- 29 mg/dL above the intensively managed long-term outcomes. Early recognition
provoking agents such as patients. This studys ndings do not and treatment of mild to moderate
glucocorticoids or vasopressors. disprove the notion that glycemic control hypoglycemia (4069 mg/dL [2.23.8
There is substantial observational in the ICU is important. However, they do mmol/L]) can prevent deterioration to a
evidence linking hyperglycemia in strongly suggest that it may not be more severe episode with potential
hospitalized patients (with or without necessary to target blood glucose values adverse sequelae (560).
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S58 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Critically Ill Patients comorbidities, as well as in those in feedings and with high dose
Based on the weight of the available patient-care settings where frequent glucocorticoid therapy (560).
evidence, for the majority of critically ill glucose monitoring or close nursing There are no data on the safety and
patients in the ICU setting, insulin supervision is not feasible. efcacy of oral agents and injectable
infusion should be used to control
Clinical judgment, combined with noninsulin therapies such as GLP-1
hyperglycemia, with a starting threshold
ongoing assessment of the patients analogs and pramlintide in the hospital.
of no higher than 180 mg/dL (10.0
clinical status, including changes in the They appear to have a limited role in
mmol/L). Once intravenous insulin is
trajectory of glucose measures, the hyperglycemia management in
started, the glucose level should be
severity of illness, nutritional status, or conjunction with acute illness.
maintained between 140 and 180 mg/dL
concomitant medications that might Continuation of these agents may be
(7.8 and 10.0 mmol/L). Greater benet
affect glucose levels (e.g., steroids, appropriate in selected stable patients
maybe realized at the lower end of this
octreotide) must be incorporated into who are expected to consume meals at
range. Although strong evidence is
the day-to-day decisions regarding regular intervals. They may be initiated
lacking, lower glucose targets may be
insulin dosing (560). or resumed in anticipation of discharge
appropriate in selected patients. One
once the patient is clinically stable.
small study suggested that ICU patients 2. Antihyperglycemic Agents in Specic caution is required with
treated to targets of 120140 had less Hospitalized Patients metformin, due to the possibility that a
negative nitrogen balance than those In most clinical situations in the hospital, contraindication may develop during
treated to higher targets (561). insulin therapy is the preferred method the hospitalization, such as renal
However, targets ,110 mg/dL of glycemic control (560). In the ICU, insufciency, unstable hemodynamic
(6.1 mmol/L) are not recommended. intravenous infusion is the preferred status, or need for an imaging study that
Insulin infusion protocols with route of insulin administration. When requires a radiocontrast dye.
demonstrated safety and efcacy, the patient is transitioned off
resulting in low rates of hypoglycemia, intravenous insulin to subcutaneous 3. Preventing Hypoglycemia
are highly recommended (560). therapy, precautions should be taken to Patients with or without diabetes may
prevent hyperglycemia escape experience hypoglycemia in the hospital
Noncritically Ill Patients setting in association with altered
With no prospective RCT data to inform (564,565). Outside of critical care units,
scheduled subcutaneous insulin that nutritional state, heart failure, renal or
specic glycemic targets in non liver disease, malignancy, infection, or
critically ill patients, recommendations delivers basal, nutritional, and
correctional (supplemental) sepsis. Additional triggering events
are based on clinical experience and leading to iatrogenic hypoglycemia
judgment (562). For the majority of components is recommended. Typical
dosing schemes are based on body include sudden reduction of
noncritically ill patients treated with corticosteroid dose, altered ability of
insulin, premeal glucose targets should weight, with some evidence that
patients with renal insufciency should the patient to report symptoms,
generally be ,140 mg/dL (7.8 mmol/L) reduced oral intake, emesis, new NPO
with random blood glucose ,180 mg/dL be treated with lower doses (566).
status, inappropriate timing of short- or
(10.0 mmol/L), as long as these targets The sole use of sliding scale insulin is rapid-acting insulin in relation to meals,
can be safely achieved. To avoid strongly discouraged in hospitalized reduced infusion rate of intravenous
hypoglycemia, consideration should be patients. A more physiological insulin dextrose, and unexpected interruption
given to reassessing the insulin regimen regimen including basal, prandial, and of enteral feedings or parenteral
if blood glucose levels fall below correctional insulin is recommended. nutrition.
100 mg/dL (5.6 mmol/L). Modifying the The insulin regimen must also
regimen is required when blood glucose Despite the preventable nature of
incorporate prandial carbohydrate
values are ,70 mg/dL (3.9 mmol/L), many inpatient episodes of
intake (567). For type 1 diabetic
unless the event is easily explained by hypoglycemia, institutions are more
patients, dosing insulin solely based on
other factors (such as a missed meal). likely to have nursing protocols for
premeal glucose would likely deliver
There is some evidence that systematic hypoglycemia treatment than for its
suboptimal insulin doses and may
attention to hyperglycemia in the prevention. Tracking such episodes
potentially lead to DKA. It increases both
emergency room leads to better and analyzing their causes are
hypoglycemia and hyperglycemia risks
glycemic control in the hospital for important quality improvement
and has been shown in a randomized
those subsequently admitted (563). activities (295).
trial to be associated with adverse
Patients with a prior history of outcomes in general surgery patients 4. Diabetes Care Providers in the
successful tight glycemic control in the with type 2 diabetes (568). The reader is Hospital
outpatient setting who are clinically referred to publications and reviews Inpatient diabetes management may be
stable may be maintained with a glucose that describe currently available insulin effectively championed and/or provided
range below the aforementioned cut preparations and protocols and provide by primary care physicians,
points. Conversely, higher glucose guidance in use of insulin therapy in endocrinologists, intensivists, or
ranges may be acceptable in terminally specic clinical settings including hospitalists. Involvement of
ill patients or in patients with severe parenteral nutrition (569), enteral tube appropriately trained specialists or
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care.diabetesjournals.org Position Statement S59

specialty teams may reduce length of calories to meet metabolic demands, commercially available capillary blood
stay, improve glycemic control, and and create a discharge plan for follow- glucose meters introduce a correction
improve outcomes (560). Standardized up care (551,573). The ADA does not factor of ;1.12 to report a plasma-
orders for scheduled and correction- endorse any single meal plan or adjusted value (578).
dose insulin should be implemented, specied percentages of macronutrients, Signicant discrepancies between
and sole reliance on a sliding scale and the term ADA diet should no capillary, venous, and arterial plasma
regimen strongly discouraged. As longer be used. Current nutrition samples have been observed in patients
hospitals move to comply with recommendations advise with low or high hemoglobin
meaningful use regulations for individualization based on treatment concentrations, hypoperfusion, and the
electronic health records, as mandated goals, physiological parameters, and presence of interfering substances
by the Health Information Technology medication use. Consistent particularly maltose, as contained in
Act, efforts should be made to assure carbohydrate meal plans are preferred immunoglobulins (579). Analytical
that all components of structured by many hospitals since they facilitate variability has been described with
insulin order sets are incorporated into matching the prandial insulin dose to the several meters (580). Increasingly
electronic insulin order sets (570,571). amount of carbohydrate consumed newer generation POC blood glucose
A team approach is needed to establish (574). Because of the complexity of meters correct for variation in
hospital pathways. To achieve glycemic nutrition issues in the hospital, a hematocrit and for interfering
targets associated with improved registered dietitian, knowledgeable and substances. Any glucose result that
hospital outcomes, hospitals will need skilled in MNT, should serve as an does not correlate with the patients
multidisciplinary support to develop inpatient team member. The dietitian is status should be conrmed through
insulin management protocols that responsible for integrating information conventional laboratory sampling of
effectively and safely enable about the patients clinical condition, plasma glucose. The FDA has become
achievement of glycemic targets (572). eating, and lifestyle habits and for increasingly concerned about the use of
establishing treatment goals in order to POC blood glucose meters in the
5. Self-Management in the Hospital determine a realistic plan for nutrition hospital and is presently reviewing
Diabetes self-management in the hospital therapy (116). matters related to their use.
may be appropriate for competent youth 7. Bedside Blood Glucose Monitoring
8. Discharge Planning and DSME
and adult patients who have a stable level Bedside POC blood glucose monitoring Transition from the acute care setting
of consciousness and reasonably stable is used to guide insulin dosing. In the is a high-risk time for all patients, not
daily insulin requirements, successfully patient receiving nutrition, the timing just those with diabetes or new
conduct self-management of diabetes at of glucose monitoring should match hyperglycemia. Although there is an
home, have physical skills needed to carbohydrate exposure. In the patient extensive literature concerning safe
successfully self-administer insulin and not receiving nutrition, glucose transition within and from the hospital,
perform SMBG, have adequate oral monitoring is performed every 46 h little of it is specic to diabetes (581).
intake, are procient in carbohydrate (575,576). More frequent blood glucose Diabetes discharge planning is not a
counting, use multiple daily insulin testing ranging from every 30 min to separate entity, but is an important part
injections or insulin pump therapy, and every 2 h is required for patients on of an overall discharge plan. As such,
understand sick-day management. The intravenous insulin infusions. discharge planning begins at
patient and physician, in consultation
Safety standards should be established admission to the hospital and is
with nursing staff, must agree that
for blood glucose monitoring updated as projected patient needs
patient self-management is appropriate
prohibiting sharing of nger-stick change.
while hospitalized.
lancing devices, lancets, needles, and Inpatients may be discharged to varied
Patients who use CSII pump therapy in meters to reduce the risk of settings, including home (with or without
the outpatient setting can be candidates transmission of blood-borne diseases. visiting nurse services), assisted living,
for diabetes self-management in the Shared lancing devices carry essentially rehabilitation, or skilled nursing facilities.
hospital, provided that they have the the same risk as sharing syringes and The latter two sites are generally staffed
mental and physical capacity to do so needles (577). by health professionals, so diabetes
(560). A hospital policy and procedures
Accuracy of blood glucose discharge planning will be limited to
delineating inpatient guidelines for CSII
measurements using POC meters has communication of medication and diet
therapy are advisable, and availability
limitations that must be considered. orders. For the patient who is discharged
of hospital personnel with expertise in
Although the FDA allows a 1/2 20% to assisted living or to home, the optimal
CSII therapy is essential. It is important
error for blood glucose meters, program will need to consider the type
that nursing personnel document basal
questions about the appropriateness of and severity of diabetes, the effects of the
rates and bolus doses taken on a daily
these criteria have been raised (388). patients illness on blood glucose levels,
basis.
Glucose measures differ signicantly and the capacities and desires of the
6. MNT in the Hospital between plasma and whole blood, terms patient. Smooth transition to outpatient
The goals of MNT are to optimize that are often used interchangeably and care should be ensured. The Agency for
glycemic control, provide adequate can lead to misinterpretation. Most Healthcare Research and Quality
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S60 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

recommends that, at a minimum, DSME should start upon admission or as plan for determining the cause of
discharge plans include the following: soon as feasible, especially in those new hyperglycemia, related complications
to insulin therapy or in whom the and comorbidities, and recommended
c Medication reconciliation: the diabetes regimen has been substantially treatments can assist outpatient
patients medications must be cross- altered during the hospitalization. providers as they assume ongoing
checked to ensure that no chronic care.
It is recommended that the following
medications were stopped and to
areas of knowledge be reviewed and B. Diabetes and Employment
ensure the safety of new
addressed prior to hospital discharge: Any person with diabetes, whether
prescriptions.
c Prescriptions for new or changed insulin treated or noninsulin treated,
c Identication of the health care
medication should be lled and should be eligible for any employment
provider who will provide diabetes for which he or she is otherwise
reviewed with the patient and care after discharge
family at or before discharge qualied. Employment decisions should
c Level of understanding related to the
c Structured discharge never be based on generalizations or
diagnosis of diabetes, SMBG, and stereotypes regarding the effects of
communication: Information on explanation of home blood glucose goals
medication changes, pending tests diabetes. When questions arise about
c Denition, recognition, treatment,
and studies, and follow-up needs the medical tness of a person with
and prevention of hyperglycemia and diabetes for a particular job, a health
must be accurately and promptly hypoglycemia
communicated to outpatient care professional with expertise in
c Information on consistent eating
physicians. treating diabetes should perform an
patterns individualized assessment. See the ADA
c Discharge summaries should be
c When and how to take blood
transmitted to the primary physician position statement on diabetes and
glucoselowering medications employment (583).
as soon as possible after discharge. including insulin administration (if
c Appointment keeping behavior is
going home on insulin) C. Diabetes and Driving
enhanced when the inpatient team c Sick-day management A large percentage of people with
schedules outpatient medical c Proper use and disposal of needles diabetes in the U.S. and elsewhere
follow-up prior to discharge. Ideally and syringes seek a license to drive, either for
the inpatient care providers or case
personal or employment purposes.
managers/discharge planners will It is important that patients be provided There has been considerable debate
schedule follow-up visit(s) with with appropriate durable medical whether, and the extent to which,
the appropriate professionals, equipment, medication, supplies and diabetes may be a relevant factor in
including primary care provider, prescriptions at the time of discharge in determining the driver ability and
endocrinologist, and diabetes order to avoid a potentially dangerous eligibility for a license.
educator (582). hiatus in care. These supplies/
People with diabetes are subject to a
prescriptions should include the
Teaching diabetes self-management to great variety of licensing requirements
following:
patients in hospitals is a challenging applied by both state and federal
task. Patients are ill, under increased c Insulin (vials or pens) if needed jurisdictions, which may lead to loss of
stress related to their hospitalization c Syringes or pen needles (if needed) employment or signicant restrictions
and diagnosis, and in an environment c Oral medications (if needed) on a persons license. Presence of a
not conducive to learning. Ideally, c Blood glucose meter and strips medical condition that can lead to
people with diabetes should be taught c Lancets and lancing device signicantly impaired consciousness or
at a time and place conducive to c Urine ketone strips (type 1) cognition may lead to drivers being
learning: as an outpatient in a c Glucagon emergency kit (insulin evaluated for tness to drive. For
recognized program of diabetes treated) diabetes, this typically arises when
education. For the hospitalized patient, c Medical alert application/charm the person has had a hypoglycemic
diabetes survival skills education is episode behind the wheel, even if
generally a feasible approach to provide More expanded diabetes education can this did not lead to a motor vehicle
sufcient information and training to be arranged in the community. An accident.
enable safe care at home. Patients outpatient follow-up visit with the Epidemiological and simulator data
hospitalized because of a crisis related primary care provider, endocrinologist, suggest that people with insulin-treated
to diabetes management or poor care at or diabetes educator within 1 month of diabetes have a small increase in risk of
home require education to prevent discharge is advised for all patients motor vehicle accidents, primarily due
subsequent episodes of hospitalization. having hyperglycemia in the hospital. to hypoglycemia and decreased
Assessing the need for a home health Clear communication with outpatient awareness of hypoglycemia. This
referral or referral to an outpatient providers either directly or via hospital increase (RR 1.121.19) is much smaller
diabetes education program should be discharge summaries facilitates safe than the risks associated with teenage
part of discharge planning for all transitions to outpatient care. Providing male drivers (RR 42), driving at night
patients. information regarding the cause or the (RR 142), driving on rural roads
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care.diabetesjournals.org Position Statement S61

compared with urban roads (RR 9.2), individual patient preferences, with chronic disease: 1) delivery system
and obstructive sleep apnea (RR 2.4), all prognoses, and comorbidities. B design (moving from a reactive to a
of which are accepted for unrestricted c A patient-centered communication proactive care delivery system where
licensure. style should be used that planned visits are coordinated through a
The ADA position statement on diabetes incorporates patient preferences, team-based approach, 2) self-
and driving (584) recommends against assesses literacy and numeracy, management support, 3) decision
blanket restrictions based on the and addresses cultural barriers to support (basing care on evidence-
diagnosis of diabetes and urges care. B based, effective care guidelines),
individual assessment by a health care 4) clinical information systems (using
professional knowledgeable in diabetes There has been steady improvement in registries that can provide patient-
if restrictions on licensure are being the proportion of diabetic patients specic and population-based support
considered. Patients should be achieving recommended levels of A1C, to the care team), 5) community
evaluated for decreased awareness of blood pressure, and LDL cholesterol in resources and policies (identifying or
hypoglycemia, hypoglycemia episodes the last 10 years, both in primary care developing resources to support
while driving, or severe hypoglycemia. settings and in endocrinology practices. healthy lifestyles), and 6) health
Patients with retinopathy or peripheral Mean A1C nationally has declined from systems (to create a quality-oriented
neuropathy require assessment to 7.82% in 19992000 to 7.18% in 2004 culture). Redenition of the roles of the
determine if those complications based on NHANES data (586). This has clinic staff and promoting self-
interfere with operation of a motor been accompanied by improvements in management on the part of the patient
vehicle. Health care professionals lipids and blood pressure control and led are fundamental to the successful
should be cognizant of the potential risk to substantial reductions in end-stage implementation of the CCM (591).
of driving with diabetes and counsel microvascular complications in those Collaborative, multidisciplinary teams
their patients about detecting and with diabetes. Nevertheless, between are best suited to provide such care for
avoiding hypoglycemia while driving. 33.4 to 48.7% of patients with diabetes people with chronic conditions such as
still do not meet targets for glycemic, diabetes and to facilitate patients
D. Diabetes Management in blood pressure, and cholesterol control, performance of appropriate self-
Correctional Institutions and only 14.3% meet targets for the management (222,224,287,592).
People with diabetes in correctional combination of all three measures and NDEP maintains an online resource
facilities should receive care that meets nonsmoking status (317). Evidence also (www.betterdiabetescare.nih.gov) to
national standards. Because it is suggests that progress in risk factor help health care professionals design
estimated that nearly 80,000 inmates control (particularly tobacco use) may and implement more effective health
have diabetes, correctional institutions be slowing (317,587). Certain patient care delivery systems for those with
should have written policies and groups, such as patients with complex diabetes. Three specic objectives, with
procedures for the management of comorbidities, nancial or other social references to literature that outlines
diabetes and for training of medical and hardships, and/or limited English practical strategies to achieve each, are
correctional staff in diabetes care prociency, may present particular outlined below.
practices. See the ADA position challenges to goal-based care (588,589).
statement on diabetes management in Persistent variation in quality of Objective 1: Optimize Provider and
correctional institutions (585) for diabetes care across providers and Team Behavior
further discussion. across practice settings even after The care team should prioritize timely
and appropriate intensication of
adjusting for patient factors indicates
lifestyle and/or pharmaceutical
X. STRATEGIES FOR IMPROVING that there remains potential for
therapy of patients who have not
DIABETES CARE substantial further improvements in
achieved benecial levels of blood
Recommendations
diabetes care.
pressure, lipid, or glucose control (593).
c Care should be aligned with While numerous interventions to Strategies such as explicit goal setting
components of the Chronic Care improve adherence to the with patients (594); identifying and
Model (CCM) to ensure productive recommended standards have been addressing language, numeracy, or
interactions between a prepared implemented, a major barrier to optimal cultural barriers to care (595598);
proactive practice team and an care is a delivery system that too often is integrating evidence-based guidelines
informed activated patient. A fragmented, lacks clinical information and clinical information tools into the
c When feasible, care systems should capabilities, often duplicates services, process of care (599601); and
support team-based care, community and is poorly designed for the incorporating care management teams
involvement, patient registries, and coordinated delivery of chronic care. including nurses, pharmacists, and
embedded decision support tools to The CCM has been shown to be an other providers (602604) have each
meet patient needs. B effective framework for improving the been shown to optimize provider and
c Treatment decisions should be timely quality of diabetes care (590). The CCM team behavior and thereby catalyze
and based on evidence-based includes six core elements for the reduction in A1C, blood pressure, and
guidelines that are tailored to provision of optimal care of patients LDL cholesterol.
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S62 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Objective 2: Support Patient Behavior incentives to improve diabetes population in 19882006. Diabetes Care
Change care (620). 2010;33:562568
Successful diabetes care requires a 12. Picon MJ, Murri M, Mu~noz A, Fernandez-
It is clear that optimal diabetes Garca JC, Gomez-Huelgas R, Tinahones FJ.
systematic approach to supporting
management requires an organized, Hemoglobin A1c versus oral glucose
patients behavior change efforts,
systematic approach and involvement tolerance test in postpartum diabetes
including 1) healthy lifestyle changes screening. Diabetes Care 2012;35:1648
of a coordinated team of dedicated
(physical activity, healthy eating, 1653
health care professionals working in an
nonuse of tobacco, weight 13. Expert Committee on the Diagnosis and
environment where patient-centered
management, effective coping); Classication of Diabetes Mellitus. Report
high-quality care is a priority.
2) disease self-management (medication of the Expert Committee on the Diagnosis
taking and management and self- and Classication of Diabetes Mellitus.
monitoring of glucose and blood References Diabetes Care 1997;20:11831197
1. American Diabetes Association. Medical 14. Genuth S, Alberti KG, Bennett P, et al.;
pressure when clinically appropriate); Management of Type 1 Diabetes.
and 3) prevention of diabetes Expert Committee on the Diagnosis and
Alexandria, VA, American Diabetes Classication of Diabetes Mellitus. Follow-
complications (self-monitoring of foot Association, 2012 up report on the diagnosis of diabetes
health; active participation in screening 2. American Diabetes Association. Medical mellitus. Diabetes Care 2003;26:3160
for eye, foot, and renal complications; Management of Type 2 Diabetes. 3167
and immunizations). High-quality DSME Alexandria, VA, American Diabetes 15. Zhang X, Gregg EW, Williamson DF, et al.
has been shown to improve patient self- Association, 2012 A1C level and future risk of diabetes:
management, satisfaction, and glucose 3. Li R, Zhang P, Barker LE, Chowdhury FM, a systematic review. Diabetes Care 2010;
control (242,605), as has delivery of Zhang X. Cost-effectiveness of 33:16651673
interventions to prevent and control 16. Selvin E, Steffes MW, Zhu H, et al. Glycated
ongoing DSMS, so that gains achieved diabetes mellitus: a systematic review.
during DSME are sustained (606608). hemoglobin, diabetes, and cardiovascular
Diabetes Care 2010;33:18721894 risk in nondiabetic adults. N Engl J Med
National DSME standards call for an 4. American Diabetes Association. Diagnosis 2010;362:800811
integrated approach that includes and classication of diabetes mellitus. 17. Ackermann RT, Cheng YJ, Williamson DF,
clinical content and skills, behavioral Diabetes Care 2014;37(Suppl. 1):S81S90 Gregg EW. Identifying adults at high risk
strategies (goal setting, problem 5. International Expert Committee. for diabetes and cardiovascular disease
solving) and addressing emotional International Expert Committee report on using hemoglobin A1c National Health and
concerns in each needed curriculum the role of the A1C assay in the diagnosis Nutrition Examination Survey 20052006.
of diabetes. Diabetes Care 2009;32: Am J Prev Med 2011;40:1117
content area.
13271334 18. Grifn SJ, Borch-Johnsen K, Davies MJ,
6. Ziemer DC, Kolm P, Weintraub WS, et al. et al. Effect of early intensive
Objective 3: Change the System of
Glucose-independent, black-white multifactorial therapy on 5-year
Care differences in hemoglobin A1c levels: cardiovascular outcomes in individuals with
The most successful practices have an a cross-sectional analysis of 2 studies. Ann type 2 diabetes detected by screening
institutional priority for providing high Intern Med 2010;152:770777 (ADDITION-Europe): a cluster-randomised
quality of care (609). Changes that have trial. Lancet 2011;378:156167
7. Kumar PR, Bhansali A, Ravikiran M, et al.
been shown to increase quality of Utility of glycated hemoglobin in 19. Kahn R, Alperin P, Eddy D, et al. Age at
diabetes care include basing care on diagnosing type 2 diabetes mellitus: initiation and frequency of screening to
a community-based study. J Clin detect type 2 diabetes: a cost-
evidence-based guidelines (610),
Endocrinol Metab 2010;95:28322835 effectiveness analysis. Lancet 2010;375:
expanding the role of teams and staff 13651374
(602,611), redesigning the processes of 8. Selvin E, Steffes MW, Ballantyne CM,
Hoogeveen RC, Coresh J, Brancati FL. 20. Erickson SC, Le L, Zakharyan A, et al. New-
care (612), implementing electronic Racial differences in glycemic markers: onset treatment-dependent diabetes
health record tools (613,614), activating a cross-sectional analysis of community- mellitus and hyperlipidemia associated
and educating patients (615,616), and based data. Ann Intern Med 2011;154: with atypical antipsychotic use in older
identifying and/or developing and 303309 adults without schizophrenia or bipolar
disorder. J Am Geriatr Soc 2012;60:474
engaging community resources and 9. Nowicka P, Santoro N, Liu H, et al. Utility of
479
public policy that support healthy hemoglobin A(1c) for diagnosing
prediabetes and diabetes in obese 21. Chiu M, Austin PC, Manuel DG, Shah BR,
lifestyles (617). Recent initiatives such Tu JV. Deriving ethnic-specic BMI cutoff
children and adolescents. Diabetes Care
as the Patient-Centered Medical Home 2011;34:13061311 points for assessing diabetes risk.
show promise to improve outcomes Diabetes Care 2011;34:17411748
10. Garca de Guadiana Romualdo L, Gonzalez
through coordinated primary care and Morales M, Albaladejo Oton MD. The 22. Sheehy A, Pandhi N, Coursin DB, et al.
offer new opportunities for team- value of hemoglobin A1c for diagnosis of Minority status and diabetes screening in
based chronic disease care (618). diabetes mellitus and other changes in an ambulatory population. Diabetes Care
Alterations in reimbursement that carbohydrate metabolism in women with 2011;34:12891294
recent gestational diabetes mellitus. 23.
Knowler WC, Barrett-Connor E, Fowler SE,
reward the provision of appropriate Endocrinology Nutrition 2012;59:362366
and high-quality care rather than et al.; Diabetes Prevention Program
[in Spanish] Research Group. Reduction in the
visit-based billing (619) and that can 11. Cowie CC, Rust KF, Byrd-Holt DD, et al. incidence of type 2 diabetes with lifestyle
accommodate the need to personalize Prevalence of diabetes and high risk for intervention or metformin. N Engl J Med
care goals may provide additional diabetes using A1C criteria in the U.S. 2002;346:393403
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S63

24. Tuomilehto J, Lindstrom J, Eriksson JG, Endocrine Society. Hemoglobin A1c recommendations on the diagnosis
et al.; Finnish Diabetes Prevention Study measurement for the diagnosis of type 2 and classication of hyperglycemia
Group. Prevention of type 2 diabetes diabetes in children. Int J Pediatr in pregnancy. Diabetes Care 2010;33:
mellitus by changes in lifestyle among Endocrinol 2012;2012:31 676682
subjects with impaired glucose 35. Kester LM, Hey H, Hannon TS. Using 46. Landon MB, Spong CY, Thom E, et al.;
tolerance. N Engl J Med 2001;344:1343 hemoglobin A1c for prediabetes and Eunice Kennedy Shriver National Institute
1350 diabetes diagnosis in adolescents: can of Child Health and Human Development
25. Pan XR, Li GW, Hu YH, et al. Effects of diet adult recommendations be upheld for Maternal-Fetal Medicine Units Network.
and exercise in preventing NIDDM in pediatric use?J Adolesc Health 2012;50: A multicenter, randomized trial of
people with impaired glucose tolerance. 321323 treatment for mild gestational diabetes.
The Da Qing IGT and Diabetes Study. N Engl J Med 2009;361:13391348
36. Wu EL, Kazzi NG, Lee JM. Cost-
Diabetes Care 1997;20:537544 effectiveness of screening strategies for 47. Crowther CA, Hiller JE, Moss JR, McPhee
26. Buchanan TA, Xiang AH, Peters RK, et al. identifying pediatric diabetes mellitus and AJ, Jeffries WS, Robinson JS; Australian
Preservation of pancreatic beta-cell dysglycemia. JAMA Pediatr 2013;167:32 Carbohydrate Intolerance Study in
function and prevention of type 2 diabetes 39 Pregnant Women (ACHOIS) Trial Group.
by pharmacological treatment of insulin Effect of treatment of gestational diabetes
37. Lipman TH, Levitt Katz LE, Ratcliffe SJ, et al.
resistance in high-risk Hispanic women. mellitus on pregnancy outcomes. N Engl J
Increasing incidence of type 1 diabetes in
Diabetes 2002;51:27962803 Med 2005;352:24772486
youth: twenty years of the Philadelphia
27. Chiasson JL, Josse RG, Gomis R, Hanefeld Pediatric Diabetes Registry. Diabetes Care 48. Vandorsten JP, Dodson WC, Espeland MA,
M, Karasik A, Laakso M; STOP-NIDDM Trial 2013;36:15971603 et al. NIH consensus development
Research Group. Acarbose for prevention conference: diagnosing gestational
38. Pettitt DJ, Talton J, Dabelea D, et al.
of type 2 diabetes mellitus: the STOP- diabetes mellitus. NIH Consens State Sci
Prevalence of diabetes mellitus in U.S.
NIDDM randomised trial. Lancet 2002; Statements 2013;29:131
youth in 2009: the SEARCH for Diabetes in
359:20722077 Youth Study. Diabetes Care. 16 September 49. Horvath K, Koch K, Jeitler K, et al. Effects of
28. Gerstein HC, Yusuf S, Bosch J, et al.; 2013 [Epub ahead of print] treatment in women with gestational
DREAM (Diabetes REduction Assessment 39. Ziegler AG, Rewers M, Simell O, et al. diabetes mellitus: systematic review and
with ramipril and rosiglitazone Seroconversion to multiple islet meta-analysis. BMJ 2010;340:c1395
Medication) Trial Investigators. Effect of autoantibodies and risk of progression to 50. Kim C, Herman WH, Cheung NW,
rosiglitazone on the frequency of diabetes diabetes in children. JAMA 2013;309: Gunderson EP, Richardson C. Comparison
in patients with impaired glucose 24732479 of hemoglobin A1c with fasting plasma
tolerance or impaired fasting glucose: glucose and 2-h postchallenge glucose for
40. Sosenko JM, Skyler JS, Palmer JP, et al.;
a randomised controlled trial. Lancet risk stratication among women with
Type 1 Diabetes TrialNet Study Group;
2006;368:10961105 recent gestational diabetes mellitus.
Diabetes Prevention Trial-Type 1 Study
29. Ramachandran A, Snehalatha C, Mary S, Group. The prediction of type 1 diabetes Diabetes Care 2011;34:19491951
Mukesh B, Bhaskar AD, Vijay V; Indian by multiple autoantibody levels and their 51. Kim C, Newton KM, Knopp RH. Gestational
Diabetes Prevention Programme (IDPP). incorporation into an autoantibody risk diabetes and the incidence of type 2
The Indian Diabetes Prevention score in relatives of type 1 diabetic diabetes: a systematic review. Diabetes
Programme shows that lifestyle patients. Diabetes Care 2013;36:2615 Care 2002;25:18621868
modication and metformin prevent type 2620
52. Tobias DK, Hu FB, Chavarro J, Rosner B,
2 diabetes in Asian Indian subjects with
41. Sorensen JS, Johannesen J, Pociot F, et al.; Mozaffarian D, Zhang C. Healthful dietary
impaired glucose tolerance (IDPP-1).
the Danish Society for Diabetes in patterns and type 2 diabetes mellitus risk
Diabetologia 2006;49:289297
Childhood and Adolescence. Residual among women with a history of
30. Johnson SL, Tabaei BP, Herman WH. The b-cell function 3 to 6 years after onset of gestational diabetes mellitus. Arch Intern
efcacy and cost of alternative strategies type 1 diabetes reduces risk of severe Med 2012;172:15661572
for systematic screening for type 2 diabetes hypoglycemia in children and adolescents.
53. Li G, Zhang P, Wang J, et al. The long-term
in the U.S. population 4574 years of age. Diabetes Care 2013;36:34543459
effect of lifestyle interventions to prevent
Diabetes Care 2005;28:307311
42. Lawrence JM, Contreras R, Chen W, Sacks diabetes in the China Da Qing Diabetes
31. Imperatore G, Boyle JP, Thompson TJ, DA. Trends in the prevalence of Prevention Study: a 20-year follow-up
et al.; SEARCH for Diabetes in Youth Study preexisting diabetes and gestational study. Lancet 2008;371:17831789
Group. Projections of type 1 and type 2 diabetes mellitus among a racially/
54. Lindstrom J, Ilanne-Parikka P, Peltonen M,
diabetes burden in the U.S. population ethnically diverse population of pregnant
et al.; Finnish Diabetes Prevention Study
aged ,20 years through 2050: dynamic women, 19992005. Diabetes Care 2008;
Group. Sustained reduction in the
modeling of incidence, mortality, and 31:899904
incidence of type 2 diabetes by lifestyle
population growth. Diabetes Care 2012;
43. Metzger BE, Lowe LP, Dyer AR, et al.; intervention: follow-up of the Finnish
35:25152520
HAPO Study Cooperative Research Group. Diabetes Prevention Study. Lancet 2006;
32. American Diabetes Association. Type 2 Hyperglycemia and adverse pregnancy 368:16731679
diabetes in children and adolescents. outcomes. N Engl J Med 2008;358:1991
55. Knowler WC, Fowler SE, Hamman RF,
Diabetes Care 2000;23:381389 2002
et al.; Diabetes Prevention Program
33. Buse JB, Kaufman FR, Linder B, Hirst K, El 44. American Diabetes Association. Standards Research Group. 10-year follow-up of
Ghormli L, Willi S; HEALTHY Study Group. of medical care in diabetesd2011. diabetes incidence and weight loss in the
Diabetes screening with hemoglobin A(1c) Diabetes Care 2011;34(Suppl. 1):S11S61 Diabetes Prevention Program Outcomes
versus fasting plasma glucose in a 45.
Metzger BE, Gabbe SG, Persson B, et al.; Study. Lancet 2009;374:16771686
multiethnic middle-school cohort. International Association of Diabetes and 56. Herman WH, Hoerger TJ, Brandle M, et al.;
Diabetes Care 2013;36:429435 Pregnancy Study Groups Consensus Panel. Diabetes Prevention Program Research
34. Kapadia C, Zeitler P; Drugs and International Association of Diabetes Group. The cost-effectiveness of lifestyle
Therapeutics Committee of the Pediatric and Pregnancy Study Groups modication or metformin in preventing
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S64 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

type 2 diabetes in adults with impaired by 0.25%. Ann Intern Med 2012;156:JC6 78. Nathan DM, Kuenen J, Borg R, Zheng H,
glucose tolerance. Ann Intern Med 2005; JC12 Schoenfeld D, Heine RJ; A1c-Derived
142:323332 68. Malanda UL, Welschen LMC, Riphagen II, Average Glucose Study Group. Translating
Dekker JM, Nijpels G, Bot SD. Self- the A1C assay into estimated average
57. Diabetes Prevention Program Research glucose values. Diabetes Care 2008;31:
Group. The 10-year cost-effectiveness of monitoring of blood glucose in patients
with type 2 diabetes mellitus who are not 14731478
lifestyle intervention or metformin for
diabetes prevention: an intent-to-treat using insulin. Cochrane Database Syst Rev 79. Rohlng CL, Wiedmeyer HM, Little RR,
analysis of the DPP/DPPOS. Diabetes Care 2012;(1):CD005060 England JD, Tennill A, Goldstein DE.
2012;35:723730 69. Sacks DB, Arnold M, Bakris GL, et al.; Dening the relationship between plasma
National Academy of Clinical glucose and HbA(1c): analysis of glucose
58. Ackermann RT, Finch EA, Brizendine E, proles and HbA(1c) in the Diabetes
Biochemistry. Position statement
Zhou H, Marrero DG. Translating the Control and Complications Trial. Diabetes
executive summary: guidelines and
Diabetes Prevention Program into the Care 2002;25:275278
recommendations for laboratory analysis
community. The DEPLOY Pilot Study. Am J
in the diagnosis and management of 80. Wilson DM, Kollman; Diabetes Research in
Prev Med 2008;35:357363
diabetes mellitus. Diabetes Care 2011;34: Children Network (DirecNet) Study Group.
59. Diabetes Prevention Program Research 14191423 Relationship of A1C to glucose
Group. Long-term safety, tolerability, and concentrations in children with type 1
70. Wang J, Zgibor J, Matthews JT, Charron-
weight loss associated with metformin in diabetes: assessments by high-frequency
Prochownik D, Sereika SM, Siminerio L.
the Diabetes Prevention Program glucose determinations by sensors.
Self-monitoring of blood glucose is
Outcomes Study. Diabetes Care 2012;35: Diabetes Care 2008;31:381385
associated with problem-solving skills in
731737
hyperglycemia and hypoglycemia. 81. Kamps JL, Hempe JM, Chalew SA. Racial
60. DREAM Trial Investigators. Incidence of Diabetes Educ 2012;38:207218 disparity in A1C independent of mean
diabetes following ramipril or blood glucose in children with type 1
71. Polonsky WH, Fisher L, Schikman CH, et al.
rosiglitazone withdrawal. Diabetes Care diabetes. Diabetes Care 2010;33:1025
Structured self-monitoring of blood
2011;34:12651269 1027
glucose signicantly reduces A1C levels in
61. Ratner RE, Christophi CA, Metzger BE, poorly controlled, noninsulin-treated type 82. The Diabetes Control and Complications
et al.; Diabetes Prevention Program 2 diabetes: results from the Structured Trial/Epidemiology of Diabetes
Research Group. Prevention of diabetes in Testing Program study. Diabetes Care Interventions and Complications Research
women with a history of gestational 2011;34:262267 Group. Retinopathy and nephropathy in
diabetes: effects of metformin and patients with type 1 diabetes four years
72. Tamborlane WV, Beck RW, Bode BW,
lifestyle interventions. J Clin Endocrinol after a trial of intensive therapy. N Engl J
et al.; Juvenile Diabetes Research
Metab 2008;93:47744779 Med 2000;342:381389
Foundation Continuous Glucose
62. Miller KM, Beck RW, Bergenstal RM, et al.; Monitoring Study Group. Continuous 83. Martin CL, Albers J, Herman WH, et al.;
T1D Exchange Clinic Network. Evidence glucose monitoring and intensive DCCT/EDIC Research Group. Neuropathy
of a strong association between frequency treatment of type 1 diabetes. N Engl J Med among the diabetes control and
of self-monitoring of blood glucose and 2008;359:14641476 complications trial cohort 8 years after
hemoglobin A1c levels in T1D Exchange trial completion. Diabetes Care 2006;29:
73. Yeh HC, Brown TT, Maruthur N, et al.
clinic registry participants. Diabetes Care 340344
Comparative effectiveness and safety of
2013;36:20092014
methods of insulin delivery and glucose 84. Ohkubo Y, Kishikawa H, Araki E, et al.
63. Ziegler R, Heidtmann B, Hilgard D, Hofer S, monitoring for diabetes mellitus: Intensive insulin therapy prevents the
Rosenbauer J, Holl R; DPV-Wiss-Initiative. a systematic review and meta-analysis. progression of diabetic microvascular
Frequency of SMBG correlates with HbA1c Ann Intern Med 2012;157:336347 complications in Japanese patients with
and acute complications in children and non-insulin-dependent diabetes mellitus:
74. Bergenstal RM, Klonoff DC, Garg SK, et al.;
adolescents with type 1 diabetes. Pediatr a randomized prospective 6-year study.
ASPIRE In-Home Study Group. Threshold-
Diabetes 2011;12:1117 Diabetes Res Clin Pract 1995;28:103117
based insulin-pump interruption for
64. Farmer A, Wade A, Goyder E, et al. Impact reduction of hypoglycemia. N Engl J Med 85. UK Prospective Diabetes Study (UKPDS)
of self monitoring of blood glucose in the 2013;369:224232 Group. Effect of intensive blood-glucose
management of patients with non-insulin control with metformin on complications
75. Bergenstal RM, Ahmann AJ, Bailey T, et al.
treated diabetes: open parallel group in overweight patients with type 2
Recommendations for standardizing
randomised trial. BMJ 2007;335:132 diabetes (UKPDS 34). Lancet 1998;352:
glucose reporting and analysis to optimize
65. OKane MJ, Bunting B, Copeland M, Coates clinical decision making in diabetes: the 854865
VE; ESMON Study Group. Efcacy of self Ambulatory Glucose Prole (AGP). 86. UK Prospective Diabetes Study (UKPDS)
monitoring of blood glucose in patients Diabetes Technol Ther 2013;15: Group. Intensive blood-glucose control
with newly diagnosed type 2 diabetes 198211 with sulphonylureas or insulin compared
(ESMON study): randomised controlled with conventional treatment and risk of
76. The Diabetes Control and Complications
trial. BMJ 2008;336:11741177 complications in patients with type 2
Trial Research Group. The effect of
66. Simon J, Gray A, Clarke P, Wade A, Neil A, intensive treatment of diabetes on the diabetes (UKPDS 33). Lancet 1998;352:
Farmer A; Diabetes Glycaemic Education development and progression of long- 837853
and Monitoring Trial Group. Cost term complications in insulin-dependent 87. Holman RR, Paul SK, Bethel MA, Matthews
effectiveness of self monitoring of blood diabetes mellitus. N Engl J Med 1993;329: DR, Neil HA. 10-year follow-up of intensive
glucose in patients with non-insulin 977986 glucose control in type 2 diabetes. N Engl J
treated type 2 diabetes: economic Med 2008;359:15771589
77. Stratton IM, Adler AI, Neil HA, et al.
evaluation of data from the DiGEM trial.
Association of glycaemia with 88. Duckworth W, Abraira C, Moritz T, et al.;
BMJ 2008;336:11771180
macrovascular and microvascular VADT Investigators. Glucose control and
67. Willett LR. ACP Journal Club. Meta- complications of type 2 diabetes (UKPDS vascular complications in veterans with
analysis: self-monitoring in non-insulin- 35): prospective observational study. BMJ type 2 diabetes. N Engl J Med 2009;360:
treated type 2 diabetes improved HbA1c 2000;321:405412 129139
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S65

89. Patel A, MacMahon S, Chalmers J, et al.; diabetes affects the response to intensive guidelines. Diabetes Care 2013;36:2035
ADVANCE Collaborative Group. Intensive glucose control in type 2 subjects: the VA 2037
blood glucose control and vascular Diabetes Trial. J Diabetes Complications 110. Kmietowicz Z. Insulin pumps improve
outcomes in patients with type 2 diabetes. 2011;25:355361 control and reduce complications in
N Engl J Med 2008;358:25602572 98. Turnbull FM, Abraira C, Anderson RJ, et al.; children with type 1 diabetes. BMJ 2013;
90. Ismail-Beigi F, Craven T, Banerji MA, et al.; Control Group. Intensive glucose control 347:f5154
ACCORD trial group. Effect of intensive and macrovascular outcomes in type 2 111. Phillip M, Battelino T, Atlas E, et al.
treatment of hyperglycaemia on diabetes [published correction appears in Nocturnal glucose control with an articial
microvascular outcomes in type 2 Diabetologia 2009;52:2470]. Diabetologia pancreas at a diabetes camp. N Engl J Med
diabetes: an analysis of the ACCORD 2009;52:22882298 2013;368:824833
randomised trial. Lancet 2010;376: 99. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch
419430 112. Wolpert HA, Atakov-Castillo A, Smith SA,
IB, Inzucchi SE, Genuth S. Individualizing Steil GM. Dietary fat acutely increases
91. Gerstein HC, Miller ME, Byington RP, et al.; glycemic targets in type 2 diabetes glucose concentrations and insulin
Action to Control Cardiovascular Risk in mellitus: implications of recent clinical requirements in patients with type 1
Diabetes Study Group. Effects of intensive trials. Ann Intern Med 2011;154: diabetes: implications for carbohydrate-
glucose lowering in type 2 diabetes. N Engl 554559 based bolus dose calculation and intensive
J Med 2008;358:25452559 100. American Diabetes Association. diabetes management. Diabetes Care
92. Nathan DM, Cleary PA, Backlund JY, et al.; Postprandial blood glucose. Diabetes Care 2013;36:810816
Diabetes Control and Complications Trial/ 2001;24:775778 113. Inzucchi SE, Bergenstal RM, Buse JB, et al.;
Epidemiology of Diabetes Interventions 101. Ceriello A, Taboga C, Tonutti L, et al. American Diabetes Association (ADA);
and Complications (DCCT/EDIC) Study Evidence for an independent and European Association for the Study of
Research Group. Intensive diabetes cumulative effect of postprandial Diabetes (EASD). Management of
treatment and cardiovascular disease in hypertriglyceridemia and hyperglycemia hyperglycemia in type 2 diabetes:
patients with type 1 diabetes. N Engl J on endothelial dysfunction and oxidative a patient-centered approach. Position
Med 2005;353:26432653 stress generation: effects of short- and statement of the American Diabetes
93. Nathan DM, Zinman B, Cleary PA, et al.; long-term simvastatin treatment. Association (ADA) and the European
Diabetes Control and Complications Trial/ Circulation 2002;106:12111218 Association for the Study of Diabetes
Epidemiology of Diabetes Interventions (EASD). Diabetes Care 2012;35:1364
102. Raz I, Wilson PW, Strojek K, et al. Effects of
and Complications (DCCT/EDIC) Research 1379
prandial versus fasting glycemia on
Group. Modern-day clinical course of type cardiovascular outcomes in type 2 114. Bennett WL, Maruthur NM, Singh S, et al.
1 diabetes mellitus after 30 years diabetes: the HEART2D trial. Diabetes Comparative effectiveness and safety of
duration: the Diabetes Control and Care 2009;32:381386 medications for type 2 diabetes: an
Complications Trial/Epidemiology of update including new drugs and 2-drug
103. Metzger BE, Buchanan TA, Coustan DR,
Diabetes Interventions and Complications combinations. Ann Intern Med 2011;154:
et al. Summary and recommendations of
and Pittsburgh Epidemiology of Diabetes 602613
the Fifth International Workshop-
Complications experience (19832005). 115. Blonde L, Merilainen M, Karwe V, Raskin P;
Conference on Gestational Diabetes
Arch Intern Med 2009;169:13071316 TITRATE Study Group. Patient-directed
Mellitus. Diabetes Care 2007;30(Suppl. 2):
94. Skyler JS, Bergenstal R, Bonow RO, et al.; S251S260 titration for achieving glycaemic goals
American Diabetes Association; American using a once-daily basal insulin analogue:
104. Kitzmiller JL, Block JM, Brown FM, et al.
College of Cardiology Foundation; an assessment of two different fasting
Managing preexisting diabetes for
American Heart Association. Intensive plasma glucose targetsdthe TITRATE
pregnancy: summary of evidence and
glycemic control and the prevention of study. Diabetes Obes Metab 2009;11:
consensus recommendations for care.
cardiovascular events: implications of the 623631
Diabetes Care 2008;31:10601079
ACCORD, ADVANCE, and VA Diabetes 116. Evert AB, Boucher JL, Cypress M, et al.
Trials: a position statement of the 105. DeWitt DE, Hirsch IB. Outpatient insulin
Nutrition therapy recommendations for the
American Diabetes Association and a therapy in type 1 and type 2 diabetes
management of adults with diabetes.
scientic statement of the American mellitus: scientic review. JAMA 2003;
Diabetes Care 2014;37(Suppl. 1):S120S143
College of Cardiology Foundation and the 289:22542264
American Heart Association. Diabetes 117. DAFNE Study Group. Training in exible,
106. Rosenstock J, Dailey G, Massi-Benedetti
Care 2009;32:187192 intensive insulin management to enable
M, Fritsche A, Lin Z, Salzman A. Reduced
dietary freedom in people with type 1
95. Riddle MC, Ambrosius WT, Brillon DJ, hypoglycemia risk with insulin glargine:
diabetes: Dose Adjustment for Normal
et al.; Action to Control Cardiovascular a meta-analysis comparing insulin glargine
Eating (DAFNE) randomised controlled
Risk in Diabetes Investigators. with human NPH insulin in type 2
trial. BMJ 2002;325:746
Epidemiologic relationships between A1C diabetes. Diabetes Care 2005;28:950955
118. Kulkarni K, Castle G, Gregory R, et al.; the
and all-cause mortality during a median 107. American Diabetes Association. Intensive
Diabetes Care and Education Dietetic
3.4-year follow-up of glycemic treatment Diabetes Management. Alexandria, VA,
Practice Group. Nutrition Practice
in the ACCORD trial. Diabetes Care 2010; American Diabetes Association, 2009
Guidelines for Type 1 Diabetes Mellitus
33:983990
108. Mooradian AD, Bernbaum M, Albert SG. positively affect dietitian practices and
96. Reaven PD, Moritz TE, Schwenke DC, et al. Narrative review: a rational approach to patient outcomes. J Am Diet Assoc 1998;
Intensive glucose lowering therapy starting insulin therapy. Ann Intern Med 98:6270
reduces cardiovascular disease events 2006;145:125134
119. Rossi MC, Nicolucci A, Di Bartolo P, et al.
in Veterans Affairs Diabetes Trial
109. Wood JR, Miller KM, Maahs DM, et al.; T1D Diabetes Interactive Diary: a new
participants with lower calcied coronary
Exchange Clinic Network. Most youth with telemedicine system enabling exible diet
atherosclerosis. Diabetes 2009;58:
type 1 diabetes in the T1D Exchange Clinic and insulin therapy while improving
26422648
Registry do not meet American Diabetes quality of life: an open-label,
97. Duckworth WC, Abraira C, Moritz TE, et al.; Association or International Society for international, multicenter, randomized
Investigators of the VADT. The duration of Pediatric and Adolescent Diabetes clinical study. Diabetes Care 2010;33:109115
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S66 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

120. Laurenzi A, Bolla AM, Panigoni G, et al. 131. Davis RM, Hitch AD, Salaam MM, Herman adjustment for normal eating (DAFNE)d
Effects of carbohydrate counting on WH, Zimmer-Galler IE, Mayer-Davis EJ. an audit of outcomes in Australia. Med J
glucose control and quality of life over TeleHealth improves diabetes self- Aust 2010;192:637640
24 weeks in adult patients with type 1 management in an underserved
142. Wolever TM, Hamad S, Chiasson JL, et al.
diabetes on continuous subcutaneous community: Diabetes TeleCare. Diabetes
Day-to-day consistency in amount and
insulin infusion: a randomized, Care 2010;33:17121717
source of carbohydrate intake associated
prospective clinical trial (GIOCAR). 132. Huang MC, Hsu CC, Wang HS, Shin SJ. with improved blood glucose control in
Diabetes Care 2011;34:823827 Prospective randomized controlled trial to type 1 diabetes. J Am Coll Nutr 1999;18:
121. Ash S, Reeves MM, Yeo S, Morrison G, evaluate effectiveness of registered 242247
Carey D, Capra S. Effect of intensive dietitian-led diabetes management on
143. Rabasa-Lhoret R, Garon J, Langelier H,
dietetic interventions on weight and glycemic and diet control in a primary care
Poisson D, Chiasson JL. Effects of meal
glycaemic control in overweight men with setting in Taiwan. Diabetes Care 2010;33:
carbohydrate content on insulin
type II diabetes: a randomised trial. Int J 233239
requirements in type 1 diabetic patients
Obes Relat Metab Disord 2003;27:797 133. Al-Shookri A, Khor GL, Chan YM, Loke SC, treated intensively with the basal-bolus
802 Al-Maskari M. Effectiveness of medical (ultralente-regular) insulin regimen.
122. Rickheim PL, Weaver TW, Flader JL, nutrition treatment delivered by dietitians Diabetes Care 1999;22:667673
Kendall DM. Assessment of group versus on glycaemic outcomes and lipid proles
144. Esposito K, Maiorino MI, Ciotola M, et al.
individual diabetes education: of Arab, Omani patients with type 2
Effects of a Mediterranean-style diet on
a randomized study. Diabetes Care 2002; diabetes. Diabet Med 2012;29:236244
the need for antihyperglycemic drug
25:269274 134. Coppell KJ, Kataoka M, Williams SM, therapy in patients with newly diagnosed
123. Miller CK, Edwards L, Kissling G, Sanville L. Chisholm AW, Vorgers SM, Mann JI. type 2 diabetes: a randomized trial. Ann
Nutrition education improves metabolic Nutritional intervention in patients with Intern Med 2009;151:306314
outcomes among older adults with type 2 diabetes who are hyperglycaemic
despite optimised drug 145. Pi-Sunyer X, Blackburn G, Brancati FL,
diabetes mellitus: results from a et al.; Look AHEAD Research Group.
randomized controlled trial. Prev Med treatmentdLifestyle Over and Above
Drugs in Diabetes (LOADD) study: Reduction in weight and cardiovascular
2002;34:252259 disease risk factors in individuals with type
randomised controlled trial. BMJ 2010;
124. Scavone G, Manto A, Pitocco D, et al. 341:c3337 2 diabetes: one-year results of the Look
Effect of carbohydrate counting and AHEAD trial. Diabetes Care 2007;30:1374
135. Tan MY, Magarey JM, Chee SS, Lee LF, Tan 1383
medical nutritional therapy on glycaemic
MH. A brief structured education
control in type 1 diabetic subjects: a pilot 146. Estruch R, Ros E, Salas-Salvado J, et al.;
programme enhances self-care practices
study. Diabet Med 2010;27:477479 PREDIMED Study Investigators. Primary
and improves glycaemic control in
125. Goldhaber-Fiebert JD, Goldhaber-Fiebert Malaysians with poorly controlled diabetes. prevention of cardiovascular disease
SN, Tristan ML, Nathan DM. Randomized Health Educ Res 2011;26:896907 with a Mediterranean diet. N Engl J Med
controlled community-based nutrition 2013;368:12791290
136. Battista MC, Labonte M, Menard J, et al.
and exercise intervention improves 147. Metz JA, Stern JS, Kris-Etherton P, et al. A
Dietitian-coached management in
glycemia and cardiovascular risk factors in randomized trial of improved weight loss
combination with annual endocrinologist
type 2 diabetic patients in rural Costa Rica. with a prepared meal plan in overweight
follow up improves global metabolic and
Diabetes Care 2003;26:2429 cardiovascular health in diabetic and obese patients: impact on
126. Ziemer DC, Berkowitz KJ, Panayioto RM, participants after 24 months. Appl Physiol cardiovascular risk reduction. Arch Intern
et al. A simple meal plan emphasizing Nutr Metab 2012;37:610620 Med 2000;160:21502158
healthy food choices is as effective as an 137. Franz MJ, Monk A, Barry B, et al. 148. West DS, DiLillo V, Bursac Z, Gore SA,
exchange-based meal plan for urban Effectiveness of medical nutrition therapy Greene PG. Motivational interviewing
African Americans with type 2 diabetes. provided by dietitians in the management improves weight loss in women with type
Diabetes Care 2003;26:17191724 of non-insulin-dependent diabetes 2 diabetes. Diabetes Care 2007;30:1081
127. Takahashi M, Araki A, Ito H. Development mellitus: a randomized, controlled clinical 1087
of a new method for simple dietary trial. J Am Diet Assoc 1995;95:10091017 149. Larsen RN, Mann NJ, Maclean E, Shaw JE.
education in elderly patients with 138. Graber AL, Elasy TA, Quinn D, Wolff K, The effect of high-protein, low-
diabetes mellitus. Nihon Rohen Igakkai Brown A. Improving glycemic control in carbohydrate diets in the treatment of
Zasshi 2002;39:527532 [in Japanese] adults with diabetes mellitus: shared type 2 diabetes: a 12 month randomised
128. Wolf AM, Conaway MR, Crowther JQ, responsibility in primary care practices. controlled trial. Diabetologia 2011;54:
et al.; Improving Control with Activity and South Med J 2002;95:684690 731740
Nutrition (ICAN) Study. Translating 139. Samann A, Muhlhauser I, Bender R, Kloos 150. Li Z, Hong K, Saltsman P, et al. Long-term
lifestyle intervention to practice in obese Ch, Muller UA. Glycaemic control and efcacy of soy-based meal replacements
patients with type 2 diabetes: Improving severe hypoglycaemia following training vs an individualized diet plan in obese
Control with Activity and Nutrition (ICAN) in exible, intensive insulin therapy to type II DM patients: relative effects on
study. Diabetes Care 2004;27:15701576 enable dietary freedom in people with weight loss, metabolic parameters, and
129. Barnard ND, Cohen J, Jenkins DJ, et al. type 1 diabetes: a prospective C-reactive protein. Eur J Clin Nutr 2005;
A low-fat vegan diet improves glycemic implementation study. Diabetologia 2005; 59:411418
control and cardiovascular risk factors in a 48:19651970 151. Brehm BJ, Lattin BL, Summer SS, et al.
randomized clinical trial in individuals with 140. Lowe J, Linjawi S, Mensch M, James K, One-year comparison of a high-
type 2 diabetes. Diabetes Care 2006;29: Attia J. Flexible eating and exible insulin monounsaturated fat diet with a high-
17771783 dosing in patients with diabetes: Results carbohydrate diet in type 2 diabetes.
130. Nield L, Moore HJ, Hooper L, et al. Dietary of an intensive self-management course. Diabetes Care 2009;32:215220
advice for treatment of type 2 diabetes Diabetes Res Clin Pract 2008;80:439443 152. Davis NJ, Tomuta N, Schechter C, et al.
mellitus in adults. Cochrane Database Syst 141. McIntyre HD, Knight BA, Harvey DM, Noud Comparative study of the effects of a
Rev 2007;(3):CD004097 MN, Hagger VL, Gilshenan KS. Dose 1-year dietary intervention of a
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S67

low-carbohydrate diet versus a low-fat diet conventional weight loss diets in severely and obesity. Nutr Clin Pract 2012;27:
on weight and glycemic control in type 2 obese adults: one-year follow-up of a 553560
diabetes. Diabetes Care 2009;32:11471152 randomized trial. Ann Intern Med 2004; 174. Bot M, Pouwer F, Assies J, Jansen EH,
140:778785 Beekman AT, de Jonge P. Supplementation
153. Guldbrand H, Dizdar B, Bunjaku B, et al. In
type 2 diabetes, randomisation to advice 164. Thomas D, Elliott EJ. Low glycaemic index, with eicosapentaenoic omega-3 fatty acid
to follow a low-carbohydrate diet or low glycaemic load, diets for diabetes does not inuence serum brain-derived
transiently improves glycaemic control mellitus. Cochrane Database Syst Rev neurotrophic factor in diabetes mellitus
compared with advice to follow a low-fat 2009;(1):CD006296 patients with major depression:
diet producing a similar weight loss. 165. He M, van Dam RM, Rimm E, Hu FB, Qi L. a randomized controlled pilot study.
Diabetologia 2012;55:21182127 Whole-grain, cereal ber, bran, and germ Neuropsychobiology 2011;63:219223
154. Krebs JD, Elley CR, Parry-Strong A, et al. intake and the risks of all-cause and 175. Mas E, Woodman RJ, Burke V, et al. The
The Diabetes Excess Weight Loss (DEWL) cardiovascular disease-specic mortality omega-3 fatty acids EPA and DHA
Trial: a randomised controlled trial of among women with type 2 diabetes decrease plasma F(2)-isoprostanes:
high-protein versus high-carbohydrate mellitus. Circulation 2010;121:21622168 results from two placebo-controlled
diets over 2 years in type 2 diabetes. 166. Institute of Medicine. Dietary Reference interventions. Free Radic Res 2010;44:
Diabetologia 2012;55:905914 Intakes: Energy, Carbohydrate, Fiber, Fat, 983990
155. Wing RR, Bolin P, Brancati FL, et al.; Look Fatty Acids, Cholesterol, Protein, and 176. Wong CY, Yiu KH, Li SW, et al. Fish-oil
AHEAD Research Group. Cardiovascular Amino Acids. Washington, D.C., National supplement has neutral effects on
effects of intensive lifestyle intervention Academies Press, 2002 vascular and metabolic function but
in type 2 diabetes. N Engl J Med 2013;369: 167. U.S. Department of Health and Human improves renal function in patients with
145154 Services. U.S. Department of Agriculture: type 2 diabetes mellitus. Diabet Med
Dietary Guideline for Americans, 2010. 2010;27:5460
156. Li TY, Brennan AM, Wedick NM,
Mantzoros C, Rifai N, Hu FB. Regular [article online], 2013. Available from 177. Malekshahi Moghadam A, Saedisomeolia
consumption of nuts is associated with a www.health.gov/dietaryguidelines/. A, Djalali M, Djazayery A, Pooya S, Sojoudi
lower risk of cardiovascular disease in Accessed 1 October 2013 F. Efcacy of omega-3 fatty acid
women with type 2 diabetes. J Nutr 2009; 168. Ros E. Dietary cis-monounsaturated fatty supplementation on serum levels of
139:13331338 acids and metabolic control in type 2 tumour necrosis factor-alpha, C-reactive
diabetes. Am J Clin Nutr 2003;78(Suppl.): protein and interleukin-2 in type 2
157. Wheeler ML, Dunbar SA, Jaacks LM, et al. diabetes mellitus patients. Singapore Med
Macronutrients, food groups, and eating 617S625S
J 2012;53:615619
patterns in the management of diabetes: 169. Elhayany A, Lustman A, Abel R, Attal-
a systematic review of the literature, Singer J, Vinker S. A low carbohydrate 178. Holman RR, Paul S, Farmer A, Tucker L,
2010. Diabetes Care 2012;35:434445 Mediterranean diet improves Stratton IM, Neil HA; Atorvastatin in
cardiovascular risk factors and diabetes Factorial with Omega-3 EE90 Risk
158. Delahanty LM, Nathan DM, Lachin JM, Reduction in Diabetes Study Group.
et al.; Diabetes Control and Complications control among overweight patients with
type 2 diabetes mellitus: a 1-year Atorvastatin in Factorial with Omega-3
Trial/Epidemiology of Diabetes. EE90 Risk Reduction in Diabetes
Association of diet with glycated prospective randomized intervention
study. Diabetes Obes Metab 2010;12: (AFORRD): a randomised controlled trial.
hemoglobin during intensive treatment of Diabetologia 2009;52:5059
type 1 diabetes in the Diabetes Control 204209
and Complications Trial. Am J Clin Nutr 170. Shai I, Schwarzfuchs D, Henkin Y, et al.; 179. Kromhout D, Geleijnse JM, de Goede J,
2009;89:518524 Dietary Intervention Randomized et al. n-3 Fatty acids, ventricular
Controlled Trial (DIRECT) Group. Weight arrhythmia-related events, and fatal
159. Vitolins MZ, Anderson AM, Delahanty L, myocardial infarction in postmyocardial
et al.; Look AHEAD Research Group. Action loss with a low-carbohydrate,
Mediterranean, or low-fat diet. N Engl J infarction patients with diabetes.
for Health in Diabetes (Look AHEAD) trial: Diabetes Care 2011;34:25152520
baseline evaluation of selected nutrients Med 2008;359:229241
and food group intake. J Am Diet Assoc 171. Brunerova L, Smejkalova V, Potockova J, 180. Bosch J, Gerstein HC, Dagenais GR, et al.;
2009;109:13671375 Andel M. A comparison of the inuence ORIGIN Trial Investigators. n-3 Fatty acids
of a high-fat diet enriched in and cardiovascular outcomes in patients
160. Oza-Frank R, Cheng YJ, Narayan KM, Gregg with dysglycemia. N Engl J Med 2012;367:
EW. Trends in nutrient intake among monounsaturated fatty acids and
conventional diet on weight loss and 309318
adults with diabetes in the United States:
metabolic parameters in obese non- 181. Hallikainen M, Kurl S, Laakso M, Miettinen
19882004. J Am Diet Assoc 2009;109:
diabetic and type 2 diabetic patients. TA, Gylling H. Plant stanol esters lower LDL
11731178
Diabet Med 2007;24:533540 cholesterol level in statin-treated
161. Azadbakht L, Fard NR, Karimi M, et al. subjects with type 1 diabetes by
172. Harris WS, Mozaffarian D, Rimm E, et al.
Effects of the Dietary Approaches to Stop interfering the absorption and synthesis
Omega-6 fatty acids and risk for
Hypertension (DASH) eating plan on of cholesterol. Atherosclerosis 2011;217:
cardiovascular disease: a science advisory
cardiovascular risks among type 2 diabetic 473478
from the American Heart Association
patients: a randomized crossover clinical
Nutrition Subcommittee of the Council on 182. Hallikainen M, Lyyra-Laitinen T, Laitinen T,
trial. Diabetes Care 2011;34:5557
Nutrition, Physical Activity, and Moilanen L, Miettinen TA, Gylling H.
162. Turner-McGrievy GM, Barnard ND, Cohen Metabolism; Council on Cardiovascular Effects of plant stanol esters on serum
J, Jenkins DJ, Gloede L, Green AA. Changes Nursing; and Council on Epidemiology and cholesterol concentrations, relative
in nutrient intake and dietary quality Prevention. Circulation 2009;119:902 markers of cholesterol metabolism and
among participants with type 2 diabetes 907 endothelial function in type 1 diabetes.
following a low-fat vegan diet or a Atherosclerosis 2008;199:432439
173. Crochemore IC, Souza AF, de Souza AC,
conventional diabetes diet for 22 weeks.
Rosado EL. v-3 Polyunsaturated fatty acid 183. Lau VW, Journoud M, Jones PJ. Plant
J Am Diet Assoc 2008;108:16361645
supplementation does not inuence body sterols are efcacious in lowering plasma
163. Stern L, Iqbal N, Seshadri P, et al. The composition, insulin resistance, and LDL and non-HDL cholesterol in
effects of low-carbohydrate versus lipemia in women with type 2 diabetes hypercholesterolemic type 2 diabetic and
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S68 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

nondiabetic persons. Am J Clin Nutr 2005; magnesium supplementation in insulin- 207. Norris SL, Engelgau MM, Narayan KM.
81:13511358 requiring type 2 diabetic patients. Diabet Effectiveness of self-management
Med 1998;15:503507 training in type 2 diabetes:
184. Lee YM, Haastert B, Scherbaum W, Hauner
195. Jorde R, Figenschau Y. Supplementation a systematic review of randomized
H. A phytosterol-enriched spread
with cholecalciferol does not improve controlled trials. Diabetes Care 2001;24:
improves the lipid prole of subjects with
glycaemic control in diabetic subjects with 561587
type 2 diabetes mellitusda randomized
controlled trial under free-living normal serum 25-hydroxyvitamin D levels. 208. Marrero DG, Ard J, Delamater AM, et al.
conditions. Eur J Nutr 2003;42:111117 Eur J Nutr 2009;48:349354 Twenty-rst century behavioral medicine:
196. Patel P, Poretsky L, Liao E. Lack of effect of a context for empowering clinicians and
185. Stampfer MJ, Hennekens CH, Manson JE,
subtherapeutic vitamin D treatment on patients with diabetes: a consensus
Colditz GA, Rosner B, Willett WC. Vitamin
glycemic and lipid parameters in type 2 report. Diabetes Care 2013;36:463470
E consumption and the risk of coronary
disease in women. N Engl J Med 1993;328: diabetes: a pilot prospective randomized 209. Norris SL, Lau J, Smith SJ, Schmid CH,
14441449 trial. J Diabetes 2010;2:3640 Engelgau MM. Self-management
197. Parekh D, Sarathi V, Shivane VK, Bandgar education for adults with type 2 diabetes:
186. Yochum LA, Folsom AR, Kushi LH. Intake of
TR, Menon PS, Shah NS. Pilot study to a meta-analysis of the effect on glycemic
antioxidant vitamins and risk of death
evaluate the effect of short-term control. Diabetes Care 2002;25:1159
from stroke in postmenopausal women.
improvement in vitamin D status on 1171
Am J Clin Nutr 2000;72:476483
glucose tolerance in patients with type 2 210. Martin D, Lange K, Sima A, et al.; SWEET
187. Hasanain B, Mooradian AD. Antioxidant
diabetes mellitus. Endocr Pract 2010;16: group. Recommendations for age-
vitamins and their inuence in diabetes
600608 appropriate education of children and
mellitus. Curr Diab Rep 2002;2:448456
198. Nikooyeh B, Neyestani TR, Farvid M, et al. adolescents with diabetes and their
188. Lonn E, Yusuf S, Hoogwerf B, et al.; HOPE parents in the European Union. Pediatr
Daily consumption of vitamin D- or
Study; MICRO-HOPE Study. Effects of Diabetes 2012;13(Suppl. 16):2028
vitamin D 1 calcium-fortied yogurt drink
vitamin E on cardiovascular and
improved glycemic control in patients 211. Committee on Quality of Health Care in
microvascular outcomes in high-risk
with type 2 diabetes: a randomized clinical America. Institute of Medicine. Crossing
patients with diabetes: results of the
trial. Am J Clin Nutr 2011;93:764771 the Quality Chasm: A New Health System
HOPE study and MICRO-HOPE substudy.
199. Soric MM, Renner ET, Smith SR. Effect of for the 21st Century. Washington,
Diabetes Care 2002;25:19191927
daily vitamin D supplementation on National Academy Press, 2001
189. Miller ER 3rd, Pastor-Barriuso R, Dalal D,
HbA1c in patients with uncontrolled type 212. Barker JM, Goehrig SH, Barriga K, et al.;
Riemersma RA, Appel LJ, Guallar E. 2 diabetes mellitus: a pilot study. J DAISY study. Clinical characteristics of
Meta-analysis: high-dosage vitamin E Diabetes 2012;4:104105 children diagnosed with type 1 diabetes
supplementation may increase all-cause through intensive screening and
mortality. Ann Intern Med 2005;142: 200. Leach MJ, Kumar S. Cinnamon for diabetes
mellitus. Cochrane Database Syst Rev follow-up. Diabetes Care 2004;27:1399
3746 1404
2012;(9):CD007170
190. Belch J, MacCuish A, Campbell I, et al.; 213. Heinrich E, Nicolaas C, de Vries NK. Self-
Prevention of Progression of Arterial 201. Yeh GY, Eisenberg DM, Kaptchuk TJ,
Phillips RS. Systematic review of herbs and management interventions for type 2
Disease and Diabetes Study Group; diabetes: a systematic review. Eur
Diabetes Registry Group; Royal College of dietary supplements for glycemic control
in diabetes. Diabetes Care 2003;26:1277 Diabetes Nurs 2010;7:7176
Physicians Edinburgh. The Prevention of
Progression of Arterial Disease and 1294 214. Frosch DL, Uy V, Ochoa S, Mangione CM.
Diabetes (POPADAD) trial: factorial 202. Bray GA, Vollmer WM, Sacks FM, Evaluation of a behavior support
randomised placebo controlled trial of Obarzanek E, Svetkey LP, Appel LJ; DASH intervention for patients with poorly
aspirin and antioxidants in patients Collaborative Research Group. A further controlled diabetes. Arch Intern Med
with diabetes and asymptomatic subgroup analysis of the effects of the 2011;171:20112017
peripheral arterial disease. BMJ 2008;337: DASH diet and three dietary sodium levels 215. McGowan P. The efcacy of diabetes
a1840 on blood pressure: results of the DASH- patient education and self-management
191. Kataja-Tuomola MK, Kontto JP, Mannisto Sodium Trial. Am J Cardiol 2004;94:222 education in type 2 diabetes. Can J
S, Albanes D, Virtamo JR. Effect of alpha- 227 Diabetes 2011;35:4653
tocopherol and beta-carotene 203. Thomas MC, Moran J, Forsblom C, et al.; 216. Cooke D, Bond R, Lawton J, et al.; U.K.
supplementation on macrovascular FinnDiane Study Group. The association NIHR DAFNE Study Group. Structured
complications and total mortality from between dietary sodium intake, ESRD, and type 1 diabetes education delivered
diabetes: results of the ATBC Study. Ann all-cause mortality in patients with type 1 within routine care: impact on glycemic
Med 2010;42:178186 diabetes. Diabetes Care 2011;34:861 control and diabetes-specic quality of
192. Balk EM, Tatsioni A, Lichtenstein AH, Lau J, 866 life. Diabetes Care 2013;36:270272
Pittas AG. Effect of chromium 204. Ekinci EI, Clarke S, Thomas MC, et al. 217. Cochran J, Conn VS. Meta-analysis of
supplementation on glucose metabolism Dietary salt intake and mortality in quality of life outcomes following diabetes
and lipids: a systematic review of patients with type 2 diabetes. Diabetes self-management training. Diabetes Educ
randomized controlled trials. Diabetes Care 2011;34:703709 2008;34:815823
Care 2007;30:21542163
205. Maillot M, Drewnowski A. A conict 218. Thorpe CT, Fahey LE, Johnson H,
193. Rodrguez-Moran M, Guerrero-Romero F. between nutritionally adequate diets and Deshpande M, Thorpe JM, Fisher EB.
Oral magnesium supplementation meeting the 2010 dietary guidelines for Facilitating healthy coping in patients with
improves insulin sensitivity and metabolic sodium. Am J Prev Med 2012;42:174179 diabetes: a systematic review. Diabetes
control in type 2 diabetic subjects: Educ 2013;39:3352
206. Haas L, Maryniuk M, Beck J, et al.; 2012
a randomized double-blind controlled
Standards Revision Task Force. National 219. Fisher L, Hessler D, Glasgow RE, et al.
trial. Diabetes Care 2003;26:11471152
standards for diabetes self-management REDEEM: a pragmatic trial to reduce
194. de Valk HW, Verkaaik R, van Rijn HJ, education and support. Diabetes Care diabetes distress. Diabetes Care 2013;36:
Geerdink RA, Struyvenberg A. Oral 2014;37(Suppl. 1):S144S153 25512558
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S69

220. Robbins JM, Thatcher GE, Webb DA, with type 2 diabetes mellitus. Cochrane 246. Boule NG, Haddad E, Kenny GP, Wells GA,
Valdmanis VG. Nutritionist visits, diabetes Database Syst Rev 2009;(1):CD005268 Sigal RJ. Effects of exercise on glycemic
classes, and hospitalization rates and 234. Shah M, Kaselitz E, Heisler M. The role of control and body mass in type 2 diabetes
charges: the Urban Diabetes Study. community health workers in diabetes: mellitus: a meta-analysis of controlled
Diabetes Care 2008;31:655660 update on current literature. Curr Diab clinical trials. JAMA 2001;286:12181227
221. Duncan I, Ahmed T, Li QE, et al. Assessing Rep 2013;13:163171 247. Colberg SR, Riddell MC. Physical Activity:
the value of the diabetes educator. 235. Heisler M, Vijan S, Makki F, Piette JD. Regulation of Glucose Metabolism,
Diabetes Educ 2011;37:638657 Diabetes control with reciprocal peer Clinicial Management Strategies, and
support versus nurse care management: Weight Control. Alexandria, VA, American
222. Piatt GA, Anderson RM, Brooks MM, et al.
a randomized trial. Ann Intern Med 2010; Diabetes Association, 2013
3-year follow-up of clinical and behavioral
improvements following a multifaceted 153:507515 248. Boule NG, Kenny GP, Haddad E, Wells GA,
diabetes care intervention: results of a 236. Heisler M. Different models to mobilize Sigal RJ. Meta-analysis of the effect of
randomized controlled trial. Diabetes peer support to improve diabetes self- structured exercise training on
Educ 2010;36:301309 management and clinical outcomes: cardiorespiratory tness in type 2
evidence, logistics, evaluation diabetes mellitus. Diabetologia 2003;46:
223. Tang TS, Funnell MM, Brown MB,
considerations and needs for future 10711081
Kurlander JE. Self-management support in
real-world settings: an empowerment- research [retraction of: Heisler M. In: Fam 249. Rejeski WJ, Ip EH, Bertoni AG, et al.; Look
based intervention. Patient Educ Couns Pract 2012;29:497]. Fam Pract 2010;27 AHEAD Research Group. Lifestyle change
2010;79:178184 (Suppl. 1):i23i32 and mobility in obese adults with type 2
237. Long JA, Jahnle EC, Richardson DM, diabetes. N Engl J Med 2012;366:1209
224. Renders CM, Valk GD, Grifn S, Wagner
Loewenstein G, Volpp KG. Peer mentoring 1217
EH, Eijk JT, Assendelft WJ. Interventions to
improve the management of diabetes and nancial incentives to improve 250. Colberg SR, Sigal RJ, Fernhall B, et al.;
mellitus in primary care, outpatient and glucose control in African American American College of Sports Medicine;
community settings. Cochrane Database veterans: a randomized trial. Ann Intern American Diabetes Association. Exercise
Syst Rev 2001;(1):CD001481 Med 2012;156:416424 and type 2 diabetes. The American College
238. Dale JR, Williams SM, Bowyer V. What of Sports Medicine and the American
225. Glazier RH, Bajcar J, Kennie NR, Willson K.
is the effect of peer support on diabetes Diabetes Association: joint position
A systematic review of interventions to
outcomes in adults? A systematic statement. Diabetes Care 2010;33:2692
improve diabetes care in socially
review. Diabet Med 2012;29:1361 2696
disadvantaged populations. Diabetes Care
2006;29:16751688 1377 251. U.S. Department of Health and Human
239. Moskowitz D, Thom DH, Hessler D, Ghorob Services. Physical Activity Guidelines for
226. Hawthorne K, Robles Y, Cannings-John R,
A, Bodenheimer T. Peer coaching to Americans [article online], 2008. Available
Edwards AG. Culturally appropriate health
improve diabetes self-management: from http://www.health.gov/
education for type 2 diabetes mellitus in
which patients benet most?J Gen Intern paguidelines/guidelines/default.aspx
ethnic minority groups. Cochrane
Database Syst Rev 2008;(3):CD006424 Med 2013;28:938942 252. Cauza E, Hanusch-Enserer U, Strasser B,
240. Foster G, Taylor SJ, Eldridge SE, Ramsay J, et al. The relative benets of endurance
227. Sarkisian CA, Brown AF, Norris KC, Wintz
Grifths CJ. Self-management education and strength training on the metabolic
RL, Mangione CM. A systematic review of
programmes by lay leaders for people factors and muscle function of people
diabetes self-care interventions for older,
with chronic conditions. Cochrane with type 2 diabetes mellitus. Arch Phys
African American, or Latino adults.
Database Syst Rev 2007;(4):CD005108 Med Rehabil 2005;86:15271533
Diabetes Educ 2003;29:467479
241. Siminerio L, Ruppert KM, Gabbay RA. Who 253. Dunstan DW, Daly RM, Owen N, et al.
228. Chodosh J, Morton SC, Mojica W, et al.
can provide diabetes self-management High-intensity resistance training
Meta-analysis: chronic disease self-
support in primary care? Findings from a improves glycemic control in older
management programs for older adults.
randomized controlled trial. Diabetes patients with type 2 diabetes. Diabetes
Ann Intern Med 2005;143:427438
Educ 2013;39:705713 Care 2002;25:17291736
229. Peyrot M, Rubin RR. Behavioral and
242. Duncan I, Birkmeyer C, Coughlin S, Li QE, 254. Castaneda C, Layne JE, Munoz-Orians L,
psychosocial interventions in diabetes:
Sherr D, Boren S. Assessing the value of et al. A randomized controlled trial of
a conceptual review. Diabetes Care 2007;
diabetes education. Diabetes Educ 2009; resistance exercise training to improve
30:24332440
35:752760 glycemic control in older adults with type
230. Anderson DR, Christison-Legay J, Proctor- 2 diabetes. Diabetes Care 2002;25:2335
243. Johnson TM, Murray MR, Huang Y.
Gray E. Self-management goal setting in a 2341
Associations between self-management
community health center: the impact of
education and comprehensive diabetes 255. Sigal RJ, Kenny GP, Wasserman DH,
goal attainment on diabetes outcomes.
clinical care. Diabetes Spectrum 2010;23: Castaneda-Sceppa C. Physical activity/
Diabetes Spectrum 2010;23:97105
4146 exercise and type 2 diabetes. Diabetes
231. Naik AD, Palmer N, Petersen NJ, et al. Care 2004;27:25182539
244. Kramer MK, McWilliams JR, Chen HY,
Comparative effectiveness of goal setting
Siminerio LM. A community-based 256. Church TS, Blair SN, Cocreham S, et al.
in diabetes mellitus group clinics:
diabetes prevention program: evaluation Effects of aerobic and resistance training
randomized clinical trial. Arch Intern Med
of the group lifestyle balance program on hemoglobin A1c levels in patients with
2011;171:453459
delivered by diabetes educators. Diabetes type 2 diabetes: a randomized controlled
232. Deakin T, McShane CE, Cade JE, Williams Educ 2011;37:659668 trial. JAMA 2010;304:22532262
RD. Group based training for self- 257. Bax JJ, Young LH, Frye RL, Bonow RO,
245. Piatt GA, Seidel MC, Powell RO, Zgibor JC.
management strategies in people with Steinberg HO, Barrett EJ; American
Comparative effectiveness of lifestyle
type 2 diabetes mellitus. Cochrane Diabetes Association. Screening for
intervention efforts in the community:
Database Syst Rev 2005;(2):CD003417 coronary artery disease in patients with
results of the Rethinking Eating and
233. Duke SA, Colagiuri S, Colagiuri R. ACTivity (REACT) study. Diabetes Care diabetes. Diabetes Care 2007;30:2729
Individual patient education for people 2013;36:202209 2736
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S70 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

258. Berger M, Berchtold P, Cuppers HJ, et al. 269. Scherrer JF, Gareld LD, Chrusciel T, et al. 282. McGuire BE, Morrison TG, Hermanns N,
Metabolic and hormonal effects of Increased risk of myocardial infarction in et al. Short-form measures of diabetes-
muscular exercise in juvenile type depressed patients with type 2 diabetes. related emotional distress: the Problem
diabetics. Diabetologia 1977;13:355365 Diabetes Care 2011;34:17291734 Areas in Diabetes Scale (PAID)-5 and
270. Sullivan MD, OConnor P, Feeney P, et al. PAID-1. Diabetologia 2010;53:6669
259. Aiello LP, Wong J, Cavallerano J, Bursell SE,
Aiello LM. Retinopathy. In Handbook of Depression predicts all-cause mortality: 283. Rubin RR, Peyrot M. Psychological issues
Exercise in Diabetes. 2nd ed.Ruderman N, epidemiological evaluation from the and treatments for people with diabetes. J
Devlin JT, Kriska A, Eds. Alexandria, VA, ACCORD HRQL substudy. Diabetes Care Clin Psychol 2001;57:457478
American Diabetes Association, 2002, p. 2012;35:17081715 284. Young-Hyman DL, Davis CL. Disordered
401413 271. Chen PC, Chan YT, Chen HF, Ko MC, Li CY. eating behavior in individuals with
260. Lemaster JW, Reiber GE, Smith DG, Population-based cohort analyses of the diabetes: importance of context,
Heagerty PJ, Wallace C. Daily weight- bidirectional relationship between type 2 evaluation, and classication. Diabetes
bearing activity does not increase the risk diabetes and depression. Diabetes Care Care 2010;33:683689
of diabetic foot ulcers. Med Sci Sports 2013;36:376382 285. Beverly EA, Hultgren BA, Brooks KM,
Exerc 2003;35:10931099 272. Pan A, Keum N, Okereke OI, et al. Ritholz MD, Abrahamson MJ, Weinger K.
260a. Smith AG, Russell J, Feldman EL, et al. Bidirectional association between Understanding physicians challenges
Lifestyle intervention for pre-diabetic depression and metabolic syndrome: when treating type 2 diabetic patients
neuropathy. Diabetes Care 2006;29; a systematic review and meta-analysis of social and emotional difculties:
12941299 epidemiological studies. Diabetes Care a qualitative study. Diabetes Care 2011;
2012;35:11711180 34:10861088
261. Pop-Busui R, Evans GW, Gerstein HC,
et al.; Action to Control Cardiovascular 273. Nicolucci A, Kovacs Burns K, Holt RI, et al.; 286. Ciechanowski P. Diapression: an
Risk in Diabetes Study Group. Effects of DAWN2 Study Group. Diabetes Attitudes, integrated model for understanding the
cardiac autonomic dysfunction on Wishes and Needs second study experience of individuals with co-occuring
mortality risk in the Action to Control (DAWN2): cross-national benchmarking diabetes and depression. Clin Diabetes
Cardiovascular Risk in Diabetes of diabetes-related psychosocial 2011;29:4350
(ACCORD) trial. Diabetes Care 2010;33: outcomes for people with diabetes. 287. Katon WJ, Lin EH, Von Korff M, et al.
15781584 Diabet Med 2013;30:767777 Collaborative care for patients with
262. Mogensen CE. Nephropathy. In Handbook 274. Fisher L, Hessler DM, Polonsky WH, depression and chronic illnesses. N Engl J
of Exercise in Diabetes. 2nd ed.Ruderman Mullan J. When is diabetes distress Med 2010;363:26112620
N, Devlin JT, Kriska A, Eds. Alexandria, VA, clinically meaningful? Establishing cut 288. Kitabchi AE, Umpierrez GE, Miles JM,
American Diabetes Association, 2002, p. points for the Diabetes Distress Scale. Fisher JN. Hyperglycemic crises in adult
433449 Diabetes Care 2012;35:259264 patients with diabetes. Diabetes Care
263. Anderson RJ, Grigsby AB, Freedland KE, 275. Fisher L, Skaff MM, Mullan JT, et al. Clinical 2009;32:13351343
et al. Anxiety and poor glycemic control: depression versus distress among patients 289. Cryer PE. Hypoglycaemia: the limiting
a meta-analytic review of the literature. with type 2 diabetes: not just a question of factor in the glycaemic management of
Int J Psychiatry Med 2002;32:235247 semantics. Diabetes Care 2007;30:542548 type I and type II diabetes. Diabetologia
264. Delahanty LM, Grant RW, Wittenberg E, 276. Fisher L, Glasgow RE, Strycker LA. The 2002;45:937948
et al. Association of diabetes-related relationship between diabetes distress 290. Whitmer RA, Karter AJ, Yaffe K,
emotional distress with diabetes and clinical depression with glycemic Quesenberry CP Jr, Selby JV. Hypoglycemic
treatment in primary care patients with control among patients with type 2 episodes and risk of dementia in older
type 2 diabetes. Diabet Med 2007;24:48 diabetes. Diabetes Care 2010;33:1034 patients with type 2 diabetes mellitus. JAMA
54 1036 2009;301:15651572
265. Anderson RJ, Freedland KE, Clouse RE, 277. Aikens JE. Prospective associations 291. Punthakee Z, Miller ME, Launer LJ, et al.;
Lustman PJ. The prevalence of comorbid between emotional distress and poor ACCORD Group of Investigators; ACCORD-
depression in adults with diabetes: outcomes in type 2 diabetes. Diabetes MIND Investigators. Poor cognitive
a meta-analysis. Diabetes Care 2001;24: Care 2012;35:24722478 function and risk of severe hypoglycemia
10691078 278. Gary TL, Safford MM, Gerzoff RB, et al. in type 2 diabetes: post hoc epidemiologic
266. Kovacs Burns K, Nicolucci A, Holt RI, et al.; Perception of neighborhood problems, analysis of the ACCORD trial. Diabetes
DAWN2 Study Group. Diabetes Attitudes, health behaviors, and diabetes outcomes Care 2012;35:787793
Wishes and Needs second study among adults with diabetes in managed 292. Jacobson AM, Musen G, Ryan CM, et al.;
(DAWN2): cross-national benchmarking care: the Translating Research Into Action Diabetes Control and Complications Trial/
indicators for family members living with for Diabetes (TRIAD) study. Diabetes Care Epidemiology of Diabetes Interventions
people with diabetes. Diabet Med 2013; 2008;31:273278 and Complications Study Research Group.
30:778788 279. Katon W, Fan MY, Unutzer J, Taylor J, Long-term effect of diabetes and its
267. Harkness E, Macdonald W, Valderas J, Pincus H, Schoenbaum M. Depression and treatment on cognitive function. N Engl J
Coventry P, Gask L, Bower P. Identifying diabetes: a potentially lethal combination. Med 2007;356:18421852
psychosocial interventions that improve J Gen Intern Med 2008;23:15711575 293. Zoungas S, Patel A, Chalmers J, et al.;
both physical and mental health in 280. Zhang X, Norris SL, Gregg EW, Cheng YJ, ADVANCE Collaborative Group. Severe
patients with diabetes: a systematic Beckles G, Kahn HS. Depressive symptoms hypoglycemia and risks of vascular events
review and meta-analysis. Diabetes Care and mortality among persons with and and death. N Engl J Med 2010;363:1410
2010;33:926930 without diabetes. Am J Epidemiol 2005; 1418
268. Bot M, Pouwer F, Zuidersma M, van Melle 161:652660 294. McCoy RG, Van Houten HK, Ziegenfuss JY,
JP, de Jonge P. Association of coexisting 281. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Shah ND, Wermers RA, Smith SA.
diabetes and depression with mortality Polonsky WH. Development of a brief Increased mortality of patients with
after myocardial infarction. Diabetes Care diabetes distress screening instrument. diabetes reporting severe hypoglycemia.
2012;35:503509 Ann Fam Med 2008;6:246252 Diabetes Care 2012;35:18971901
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S71

295. Seaquist ER, Anderson J, Childs B, et al. surgically induced weight loss for the Joint National Committee on
Hypoglycemia and diabetes: a report of a management of type 2 diabetes: Prevention, Detection, Evaluation, and
workgroup of the American Diabetes a randomized controlled trial. Diabetes Treatment of High Blood Pressure;
Association and The Endocrine Society. Care 2009;32:580584 National High Blood Pressure Education
Diabetes Care 2013;36:13841395 309. Maciejewski ML, Livingston EH, Smith VA, Program Coordinating Committee. The
et al. Survival among high-risk patients Seventh Report of the Joint National
296. Cryer PE. Diverse causes of hypoglycemia-
after bariatric surgery. JAMA 2011;305: Committee on Prevention, Detection,
associated autonomic failure in diabetes.
24192426 Evaluation, and Treatment of High Blood
N Engl J Med 2004;350:22722279
Pressure: the JNC 7 report. JAMA 2003;
297. Ikramuddin S, Korner J, Lee WJ, et al. Roux- 310. Himpens J, Cadiere GB, Bazi M, Vouche M, 289:25602572
en-Y gastric bypass vs intensive medical Cadiere B, Dapri G. Long-term outcomes
of laparoscopic adjustable gastric 321. Lewington S, Clarke R, Qizilbash N, Peto R,
management for the control of type 2
banding. Arch Surg 2011;146:802807 Collins R; Prospective Studies
diabetes, hypertension, and
Collaboration. Age-specic relevance of
hyperlipidemia: the Diabetes Surgery 311. Smith SA, Poland GA. Use of inuenza and usual blood pressure to vascular
Study randomized clinical trial. JAMA pneumococcal vaccines in people with mortality: a meta-analysis of individual
2013;309:22402249 diabetes. Diabetes Care 2000;23:95108 data for one million adults in 61
298. Schauer PR, Kashyap SR, Wolski K, et al. 312. Colquhoun AJ, Nicholson KG, Botha JL, prospective studies. Lancet 2002;360:
Bariatric surgery versus intensive medical Raymond NT. Effectiveness of inuenza 19031913
therapy in obese patients with diabetes. vaccine in reducing hospital admissions in 322. Stamler J, Vaccaro O, Neaton JD,
N Engl J Med 2012;366:15671576 people with diabetes. Epidemiol Infect Wentworth D. Diabetes, other risk factors,
299. Mingrone G, Panunzi S, De Gaetano A, 1997;119:335341 and 12-yr cardiovascular mortality for
et al. Bariatric surgery versus conventional 313. Bridges CB, Fukuda K, Uyeki TM, Cox NJ, men screened in the Multiple Risk Factor
medical therapy for type 2 diabetes. Singleton JA; Centers for Disease Control Intervention Trial. Diabetes Care 1993;16:
N Engl J Med 2012;366:15771585 and Prevention, Advisory Committee on 434444
300. Dorman RB, Serrot FJ, Miller CJ, et al. Case- Immunization Practices. Prevention and 323. UK Prospective Diabetes Study Group.
matched outcomes in bariatric surgery for control of inuenza. Recommendations of Tight blood pressure control and risk of
treatment of type 2 diabetes in the the Advisory Committee on Immunization macrovascular and microvascular
morbidly obese patient. Ann Surg 2012; Practices (ACIP). MMWR Recomm Rep complications in type 2 diabetes: UKPDS
255:287293 2002;51(RR-3):131 38. BMJ 1998;317:703713
301. Buchwald H, Estok R, Fahrbach K, et al. 314. Centers for Disease Control and 324. Hansson L, Zanchetti A, Carruthers SG,
Weight and type 2 diabetes after bariatric Prevention. Use of hepatitis B vaccination et al.; HOT Study Group. Effects of
surgery: systematic review and meta- for adults with diabetes mellitus: intensive blood-pressure lowering and
analysis. Am J Med 2009;122:248256.e5 recommendations of the Advisory low-dose aspirin in patients with
Committe on Immunization Practices hypertension: principal results of the
302. Dixon JB, OBrien PE, Playfair J, et al. (ACIP). MMWR Morb Mortal Wkly Rep
Adjustable gastric banding and Hypertension Optimal Treatment (HOT)
2011;60:17091711 randomised trial. Lancet 1998;351:1755
conventional therapy for type 2 diabetes:
315. Buse JB, Ginsberg HN, Bakris GL, et al.; 1762
a randomized controlled trial. JAMA 2008;
299:316323 American Heart Association; American 325. Adler AI, Stratton IM, Neil HA, et al.
Diabetes Association. Primary prevention Association of systolic blood pressure with
303. Cohen RV, Pinheiro JC, Schiavon CA, Salles of cardiovascular diseases in people with macrovascular and microvascular
JE, Wajchenberg BL, Cummings DE. Effects diabetes mellitus: a scientic statement complications of type 2 diabetes (UKPDS
of gastric bypass surgery in patients with from the American Heart Association and 36): prospective observational study. BMJ
type 2 diabetes and only mild obesity. the American Diabetes Association. 2000;321:412419
Diabetes Care 2012;35:14201428 Diabetes Care 2007;30:162172
326. Cushman WC, Evans GW, Byington RP,
304. Buchwald H, Estok R, Fahrbach K, Banel D, 316. Gaede P, Lund-Andersen H, Parving HH, et al.; ACCORD Study Group. Effects of
Sledge I. Trends in mortality in bariatric Pedersen O. Effect of a multifactorial intensive blood-pressure control in type 2
surgery: a systematic review and meta- intervention on mortality in type 2 diabetes mellitus. N Engl J Med 2010;362:
analysis. Surgery 2007;142:621632; diabetes. N Engl J Med 2008;358:580591 15751585
discussion 632635
317. Ali MK, Bullard KM, Saaddine JB, Cowie CC, 327. Patel A, MacMahon S, Chalmers J, et al.;
305. Sjostrom L, Narbro K, Sjostrom CD, et al.; Imperatore G, Gregg EW. Achievement of ADVANCE Collaborative Group. Effects
Swedish Obese Subjects Study. Effects of goals in U.S. diabetes care, 19992010. N of a xed combination of perindopril and
bariatric surgery on mortality in Swedish Engl J Med 2013;368:16131624 indapamide on macrovascular and
obese subjects. N Engl J Med 2007;357:
318. Bobrie G, Genes N, Vaur L, et al. Is microvascular outcomes in patients with
741752
isolated home hypertension as opposed type 2 diabetes mellitus (the ADVANCE
306. Hoerger TJ, Zhang P, Segel JE, Kahn HS, to isolated ofce hypertension a sign of trial): a randomised controlled trial.
Barker LE, Couper S. Cost-effectiveness of greater cardiovascular risk?Arch Intern Lancet 2007;370:829840
bariatric surgery for severely obese adults Med 2001;161:22052211 328. Cooper-DeHoff RM, Gong Y, Handberg
with diabetes. Diabetes Care 2010;33:
319. Sega R, Facchetti R, Bombelli M, et al. EM, et al. Tight blood pressure control and
19331939
Prognostic value of ambulatory and home cardiovascular outcomes among
307. Makary MA, Clark JM, Shore AD, et al. blood pressures compared with ofce hypertensive patients with diabetes and
Medication utilization and annual health blood pressure in the general population: coronary artery disease. JAMA 2010;304:
care costs in patients with type 2 diabetes follow-up results from the Pressioni 6168
mellitus before and after bariatric surgery Arteriose Monitorate e Loro Associazioni 329. Sleight P, Redon J, Verdecchia P, et al.;
[published correction appears in Arch Surg (PAMELA) study. Circulation 2005;111: ONTARGET investigators. Prognostic value
2011;146:659]. Arch Surg 2010;145:726731 17771783 of blood pressure in patients with high
308. Keating CL, Dixon JB, Moodie ML, Peeters 320. Chobanian AV, Bakris GL, Black HR, et al.; vascular risk in the Ongoing Telmisartan
A, Playfair J, OBrien PE. Cost-efcacy of National Heart, Lung, and Blood Institute Alone and in combination with Ramipril
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S72 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

Global Endpoint Trial study. J Hypertens inhibitors: the CHARM-Added trial. Lancet 350. Collins R, Armitage J, Parish S, Sleigh P,
2009;27:13601369 2003;362:767771 Peto R; Heart Protection Study
330. McBrien K, Rabi DM, Campbell N, et al. 340. Pfeffer MA, Swedberg K, Granger CB, Collaborative Group. MRC/BHF Heart
Intensive and standard blood pressure et al.; CHARM Investigators and Protection Study of cholesterol-lowering
targets in patients with type 2 diabetes Committees. Effects of candesartan on with simvastatin in 5963 people with
mellitus: systematic review and meta- mortality and morbidity in patients with diabetes: a randomised placebo-
analysis. Arch Intern Med 2012;172:1296 chronic heart failure: the CHARM-Overall controlled trial. Lancet 2003;361:2005
1303 programme. Lancet 2003;362:759766 2016

331. Bangalore S, Kumar S, Lobach I, Messerli 341. Granger CB, McMurray JJ, Yusuf S, et al.; 351. Goldberg RB, Mellies MJ, Sacks FM, et al.;
FH. Blood pressure targets in subjects with CHARM Investigators and Committees. The Care Investigators. Cardiovascular
type 2 diabetes mellitus/impaired fasting Effects of candesartan in patients with events and their reduction with
glucose: observations from traditional and chronic heart failure and reduced left- pravastatin in diabetic and glucose-
bayesian random-effects meta-analyses of ventricular systolic function intolerant to intolerant myocardial infarction survivors
randomized trials. Circulation 2011;123: angiotensin-converting-enzyme with average cholesterol levels: subgroup
27992810 inhibitors: the CHARM-Alternative trial. analyses in the Cholesterol And Recurrent
Lancet 2003;362:772776 Events (CARE) trial. Circulation 1998;98:
332. Sacks FM, Svetkey LP, Vollmer WM, et al.; 25132519
DASH-Sodium Collaborative Research 342. Lindholm LH, Ibsen H, Dahlof B, et al.; LIFE
Group. Effects on blood pressure of Study Group. Cardiovascular morbidity 352. Shepherd J, Barter P, Carmena R, et al.
reduced dietary sodium and the Dietary and mortality in patients with diabetes in Effect of lowering LDL cholesterol
Approaches to Stop Hypertension (DASH) the Losartan Intervention For Endpoint substantially below currently
diet. N Engl J Med 2001;344:310 reduction in hypertension study (LIFE): recommended levels in patients with
a randomised trial against atenolol. Lancet coronary heart disease and diabetes: the
333. Tatti P, Pahor M, Byington RP, et al. Treating to New Targets (TNT) study.
Outcome results of the Fosinopril Versus 2002;359:10041010
Diabetes Care 2006;29:12201226
Amlodipine Cardiovascular Events 343. Berl T, Hunsicker LG, Lewis JB, et al.;
Randomized Trial (FACET) in patients with Irbesartan Diabetic Nephropathy Trial. 353. Sever PS, Poulter NR, Dahlof B, et al.
hypertension and NIDDM. Diabetes Care Collaborative Study Group. Cardiovascular Reduction in cardiovascular events with
1998;21:597603 outcomes in the Irbesartan Diabetic atorvastatin in 2,532 patients with type 2
Nephropathy Trial of patients with type 2 diabetes: Anglo-Scandinavian Cardiac
334. Estacio RO, Jeffers BW, Hiatt WR, Outcomes TrialdLipid-Lowering Arm
Biggerstaff SL, Gifford N, Schrier RW. The diabetes and overt nephropathy. Ann
Intern Med 2003;138:542549 (ASCOT-LLA). Diabetes Care 2005;28:
effect of nisoldipine as compared with 11511157
enalapril on cardiovascular outcomes in 344. McManus RJ, Mant J, Bray EP, et al.
patients with non-insulin-dependent Telemonitoring and self-management in 354. Knopp RH, dEmden M, Smilde JG, Pocock
diabetes and hypertension. N Engl J Med the control of hypertension (TASMINH2): SJ. Efcacy and safety of atorvastatin in
1998;338:645652 a randomised controlled trial. Lancet the prevention of cardiovascular end
2010;376:163172 points in subjects with type 2 diabetes: the
335. Schrier RW, Estacio RO, Mehler PS, Hiatt Atorvastatin Study for Prevention of
WR. Appropriate blood pressure control in 345. Hermida RC, Ayala DE, Mojon A, Coronary Heart Disease Endpoints in non-
hypertensive and normotensive type 2 Fernandez JR. Inuence of time of day of insulin-dependent diabetes mellitus
diabetes mellitus: a summary of the ABCD blood pressure-lowering treatment on (ASPEN). Diabetes Care 2006;29:1478
trial. Nat Clin Pract Nephrol 2007;3:428 cardiovascular risk in hypertensive 1485
438 patients with type 2 diabetes. Diabetes
Care 2011;34:12701276 355. Colhoun HM, Betteridge DJ, Durrington
336. ALLHAT Ofcers and Coordinators for the
PN, et al.; CARDS investigators. Primary
ALLHAT Collaborative Research Group. 346. Sibai BM. Treatment of hypertension in
prevention of cardiovascular disease with
Major outcomes in high-risk hypertensive pregnant women. N Engl J Med 1996;335:
atorvastatin in type 2 diabetes in the
patients randomized to angiotensin- 257265
Collaborative Atorvastatin Diabetes Study
converting enzyme inhibitor or calcium 347. Baigent C, Keech A, Kearney PM, et al.; (CARDS): multicentre randomised
channel blocker vs diuretic: the Cholesterol Treatment Trialists (CTT) placebo-controlled trial. Lancet 2004;364:
Antihypertensive and Lipid-Lowering Collaborators. Efcacy and safety of 685696
Treatment to Prevent Heart Attack Trial cholesterol-lowering treatment:
(ALLHAT). JAMA 2002;288:29812997 356. Kearney PM, Blackwell L, Collins R, et al.;
prospective meta-analysis of data from
Cholesterol Treatment Trialists (CTT)
337. Psaty BM, Smith NL, Siscovick DS, et al. 90,056 participants in 14 randomised trials
Collaborators. Efcacy of cholesterol-
Health outcomes associated with of statins. Lancet 2005;366:12671278
lowering therapy in 18,686 people with
antihypertensive therapies used as rst- 348. Mihaylova B, Emberson J, Blackwell L, diabetes in 14 randomised trials of
line agents. A systematic review and meta- et al.; Cholesterol Treatment Trialists statins: a meta-analysis. Lancet 2008;371:
analysis. JAMA 1997;277:739745 (CTT) Collaborators. The effects of 117125
338. Heart Outcomes Prevention Evaluation lowering LDL cholesterol with statin
357. Taylor F, Huffman MD, Macedo AF, et al.
Study Investigators. Effects of ramipril on therapy in people at low risk of vascular
Statins for the primary prevention of
cardiovascular and microvascular disease: meta-analysis of individual data
cardiovascular disease. Cochrane
outcomes in people with diabetes from 27 randomised trials. Lancet 2012;
Database Syst Rev 2013;(1):CD004816
mellitus: results of the HOPE study and 380:581590
MICRO-HOPE substudy. Lancet 2000;355: 358. Carter AA, Gomes T, Camacho X, Juurlink
349. Pyorala K, Pedersen TR, Kjekshus J,
253259 DN, Shah BR, Mamdani MM. Risk of
Faergeman O, Olsson AG, Thorgeirsson G.
incident diabetes among patients treated
339. McMurray JJ, Ostergren J, Swedberg K, Cholesterol lowering with simvastatin
with statins: population based study. BMJ
et al.; CHARM Investigators and improves prognosis of diabetic patients
2013;346:f2610
Committees. Effects of candesartan in with coronary heart disease. A subgroup
patients with chronic heart failure and analysis of the Scandinavian Simvastatin 359. Rajpathak SN, Kumbhani DJ, Crandall J,
reduced left-ventricular systolic function Survival Study (4S). Diabetes Care 1997; Barzilai N, Alderman M, Ridker PM. Statin
taking angiotensin-converting-enzyme 20:614620 therapy and risk of developing type 2
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S73

diabetes: a meta-analysis. Diabetes Care National Cholesterol Education Program participant data from randomised trials.
2009;32:19241929 Adult Treatment Panel III guidelines. Lancet 2009;373:18491860
Circulation 2004;110:227239
360. Sattar N, Preiss D, Murray HM, et al. Statins 382. Perk J, De Backer G, Gohlke H, et al.;
and risk of incident diabetes: a collaborative 372. Hayward RA, Hofer TP, Vijan S. Narrative European Association for Cardiovascular
meta-analysis of randomised statin trials. review: lack of evidence for recommended Prevention & Rehabilitation (EACPR); ESC
Lancet 2010;375:735742 low-density lipoprotein treatment Committee for Practice Guidelines (CPG).
targets: a solvable problem. Ann Intern European guidelines on cardiovascular
361. Ridker PM, Danielson E, Fonseca FA, et al.;
Med 2006;145:520530 disease prevention in clinical practice
JUPITER Study Group. Rosuvastatin to
prevent vascular events in men and 373. Cannon CP, Braunwald E, McCabe CH, (version 2012). The Fifth Joint Task Force
women with elevated C-reactive protein. et al.; Pravastatin or Atorvastatin of the European Society of Cardiology and
N Engl J Med 2008;359:21952207 Evaluation and Infection Therapy- Other Societies on Cardiovascular Disease
Thrombolysis in Myocardial Infarction 22 Prevention in Clinical Practice (constituted
362. Ridker PM, Pradhan A, MacFadyen JG, by representatives of nine societies and by
Investigators. Intensive versus moderate
Libby P, Glynn RJ. Cardiovascular benets invited experts). Eur Heart J 2012;33:
lipid lowering with statins after acute
and diabetes risks of statin therapy in 16351701
coronary syndromes. N Engl J Med 2004;
primary prevention: an analysis from the
350:14951504 383. Ogawa H, Nakayama M, Morimoto T,
JUPITER trial. Lancet 2012;380:565571
374. de Lemos JA, Blazing MA, Wiviott SD, et al. et al.; Japanese Primary Prevention of
363. Singh IM, Shishehbor MH, Ansell BJ. High- Atherosclerosis With Aspirin for Diabetes
Early intensive vs a delayed conservative
density lipoprotein as a therapeutic (JPAD) Trial Investigators. Low-dose
simvastatin strategy in patients with acute
target: a systematic review. JAMA 2007; aspirin for primary prevention of
coronary syndromes: phase Z of the A to Z
298:786798 atherosclerotic events in patients with
trial. JAMA 2004;292:13071316
364. Canner PL, Berge KG, Wenger NK, et al. type 2 diabetes: a randomized controlled
375. Nissen SE, Tuzcu EM, Schoenhagen P, trial. JAMA 2008;300:21342141
Fifteen year mortality in Coronary Drug
et al.; REVERSAL Investigators. Effect of
Project patients: long-term benet with 384. Pignone M, Earnshaw S, Tice JA, Pletcher
intensive compared with moderate lipid-
niacin. J Am Coll Cardiol 1986;8:1245 MJ. Aspirin, statins, or both drugs for the
lowering therapy on progression of
1255 primary prevention of coronary heart
coronary atherosclerosis: a randomized
365. Rubins HB, Robins SJ, Collins D, et al.; controlled trial. JAMA 2004;291:1071 disease events in men: a cost-utility analysis.
Veterans Affairs High-Density Lipoprotein 1080 Ann Intern Med 2006;144:326336
Cholesterol Intervention Trial Study 385. Pignone M, Alberts MJ, Colwell JA, et al.;
376. Brunzell JD, Davidson M, Furberg CD,
Group. Gembrozil for the secondary American Diabetes Association; American
et al.; American Diabetes Association;
prevention of coronary heart disease in Heart Association; American College of
American College of Cardiology
men with low levels of high-density Cardiology Foundation. Aspirin for
Foundation. Lipoprotein management in
lipoprotein cholesterol. N Engl J Med primary prevention of cardiovascular
patients with cardiometabolic risk:
1999;341:410418 events in people with diabetes: a position
consensus statement from the American
366. Frick MH, Elo O, Haapa K, et al. Helsinki Diabetes Association and the American statement of the American Diabetes
Heart Study: primary-prevention trial with College of Cardiology Foundation. Association, a scientic statement of the
gembrozil in middle-aged men with Diabetes Care 2008;31:811822 American Heart Association, and an expert
dyslipidemia. Safety of treatment, consensus document of the American
377. Chasman DI, Posada D, Subrahmanyan L, College of Cardiology Foundation.
changes in risk factors, and incidence of
Cook NR, Stanton VP Jr, Ridker PM. Diabetes Care 2010;33:13951402
coronary heart disease. N Engl J Med
Pharmacogenetic study of statin therapy
1987;317:12371245 386. Campbell CL, Smyth S, Montalescot G,
and cholesterol reduction. JAMA 2004;
367. Keech A, Simes RJ, Barter P, et al.; FIELD 291:28212827 Steinhubl SR. Aspirin dose for the
study investigators. Effects of long-term prevention of cardiovascular disease:
378. Meek C, Wierzbicki AS, Jewkes C, et al.
fenobrate therapy on cardiovascular a systematic review. JAMA 2007;297:
Daily and intermittent rosuvastatin 5 mg
events in 9795 people with type 2 20182024
therapy in statin intolerant patients: an
diabetes mellitus (the FIELD study): 387. Dav G, Patrono C. Platelet activation and
observational study. Curr Med Res Opin
randomised controlled trial. Lancet 2005; atherothrombosis. N Engl J Med 2007;357:
2012;28:371378
366:18491861 24822494
379. Elam MB, Hunninghake DB, Davis KB, et al.
368. Jones PH, Davidson MH. Reporting rate of 388. Vandvik PO, Lincoff AM, Gore JM, et al.
Effect of niacin on lipid and lipoprotein
rhabdomyolysis with fenobrate 1 statin Primary and secondary prevention of
levels and glycemic control in patients
versus gembrozil 1 any statin. Am J cardiovascular disease: Antithrombotic
with diabetes and peripheral arterial
Cardiol 2005;95:120122 Therapy and Prevention of Thrombosis,
disease. The ADMIT study: a randomized
369. Ginsberg HN, Elam MB, Lovato LC, et al.; trial. JAMA 2000;284:12631270 9th ed: American College of Chest
ACCORD Study Group. Effects of Physicians Evidence-Based Clinical
380. Grundy SM, Vega GL, McGovern ME, et al.;
combination lipid therapy in type 2 Practice Guidelines. Chest 2012;141:
Diabetes Multicenter Research Group.
diabetes mellitus. N Engl J Med 2010;362: e637Se668S
Efcacy, safety, and tolerability of once-
15631574 389. Voulgari C, Katsilambros N, Tentolouris N.
daily niacin for the treatment of
370. Boden WE, Probsteld JL, Anderson T, dyslipidemia associated with type 2 Smoking cessation predicts amelioration
et al.; AIM-HIGH Investigators. Niacin in diabetes: results of the assessment of of microalbuminuria in newly diagnosed
patients with low HDL cholesterol levels diabetes control and evaluation of the type 2 diabetes mellitus: a 1-year
receiving intensive statin therapy. N Engl J efcacy of niaspan trial. Arch Intern Med prospective study. Metabolism 2011;60:
Med 2011;365:22552267 2002;162:15681576 14561464
371. Grundy SM, Cleeman JI, Merz CN, et al.; 381. Baigent C, Blackwell L, Collins R, et al.; 390. Ranney L, Melvin C, Lux L, McClain E, Lohr
National Heart, Lung, and Blood Institute; Antithrombotic Trialists (ATT) KN. Systematic review: smoking cessation
American College of Cardiology Collaboration. Aspirin in the primary and intervention strategies for adults and
Foundation; American Heart Association. secondary prevention of vascular disease: adults in special populations. Ann Intern
Implications of recent clinical trials for the collaborative meta-analysis of individual Med 2006;145:845856
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S74 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

391. Clair C, Rigotti NA, Porneala B, et al. cardiovascular events in asymptomatic of incipient and overt diabetic
Association of smoking cessation and patients with type 2 diabetes: the PREDICT nephropathy in patients with non-insulin
weight change with cardiovascular study. Eur Heart J 2008;29:22442251 dependent diabetes mellitus: prospective,
disease among adults with and without 402. Choi EK, Chun EJ, Choi SI, et al. Assessment observational study. BMJ 1997;314:783
diabetes. JAMA 2013;309:10141021 of subclinical coronary atherosclerosis in 788
392. Braunwald E, Domanski MJ, Fowler SE, asymptomatic patients with type 2 412. Ravid M, Lang R, Rachmani R, Lishner M.
et al.; PEACE Trial Investigators. diabetes mellitus with single photon Long-term renoprotective effect of
Angiotensin-converting-enzyme emission computed tomography and angiotensin-converting enzyme inhibition
inhibition in stable coronary artery coronary computed tomography in non-insulin-dependent diabetes
disease. N Engl J Med 2004;351:2058 angiography. Am J Cardiol 2009;104:890 mellitus. A 7-year follow-up study. Arch
2068 896 Intern Med 1996;156:286289
393. Yusuf S, Teo K, Anderson C, et al.; 403. Eurich DT, Weir DL, Majumdar SR, et al. 413. The Diabetes Control and Complications
Telmisartan Randomised AssessmeNt Comparative safety and effectiveness of (DCCT) Research Group. Effect of intensive
Study in ACE iNtolerant subjects with metformin in patients with diabetes therapy on the development and
cardiovascular Disease (TRANSCEND) mellitus and heart failure: systematic progression of diabetic nephropathy in
Investigators. Effects of the angiotensin- review of observational studies involving the Diabetes Control and Complications
receptor blocker telmisartan on 34,000 patients. Circ Heart Fail 2013;6: Trial. Kidney Int 1995;47:17031720
cardiovascular events in high-risk patients 395402
414. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD;
intolerant to angiotensin-converting 404. Krolewski AS, Niewczas MA, Skupien J,
enzyme inhibitors: a randomised the Collaborative Study Group. The effect
et al. Early progressive renal decline of angiotensin-converting-enzyme
controlled trial. Lancet 2008;372:1174 precedes the onset of microalbuminuria
1183 inhibition on diabetic nephropathy. N Engl
and its progression to macroalbuminuria. J Med 1993;329:14561462
394. Boden WE, ORourke RA, Teo KK, et al.; Diabetes Care 2014;37:226234
COURAGE Trial Research Group. Optimal 415. Laffel LM, McGill JB, Gans DJ; North
405. Garg JP, Bakris GL. Microalbuminuria: American Microalbuminuria Study Group.
medical therapy with or without PCI for marker of vascular dysfunction, risk factor
stable coronary disease. N Engl J Med The benecial effect of angiotensin-
for cardiovascular disease. Vasc Med converting enzyme inhibition with
2007;356:15031516 2002;7:3543 captopril on diabetic nephropathy in
395. Frye RL, August P, Brooks MM, et al.; BARI 406. Klausen K, Borch-Johnsen K, Feldt- normotensive IDDM patients with
2D Study Group. A randomized trial of Rasmussen B, et al. Very low levels of microalbuminuria. Am J Med 1995;99:
therapies for type 2 diabetes and coronary microalbuminuria are associated with 497504
artery disease. N Engl J Med 2009;360: increased risk of coronary heart disease
25032515 416. Remuzzi G, Macia M, Ruggenenti P.
and death independently of renal Prevention and treatment of diabetic
396. Wackers FJ, Chyun DA, Young LH, et al.; function, hypertension, and diabetes. renal disease in type 2 diabetes: the
Detection of Ischemia in Asymptomatic Circulation 2004;110:3235 BENEDICT study. J Am Soc Nephrol 2006;
Diabetics (DIAD) Investigators. Resolution 407. de Boer IH, Rue TC, Cleary PA, et al.; 17(Suppl. 2):S90S97
of asymptomatic myocardial ischemia in Diabetes Control and Complications
patients with type 2 diabetes in the 417. Haller H, Ito S, Izzo JL Jr, et al.; ROADMAP
Trial/Epidemiology of Diabetes Trial Investigators. Olmesartan for the
Detection of Ischemia in Asymptomatic Interventions and Complications Study
Diabetics (DIAD) study. Diabetes Care delay or prevention of microalbuminuria
Research Group. Long-term renal in type 2 diabetes. N Engl J Med 2011;364:
2007;30:28922898 outcomes of patients with type 1 907917
397. Young LH, Wackers FJ, Chyun DA, et al.; diabetes mellitus and microalbuminuria:
DIAD Investigators. Cardiac outcomes an analysis of the Diabetes Control and 418. Bilous R, Chaturvedi N, Sjlie AK,
after screening for asymptomatic Complications Trial/Epidemiology of et al. Effect of candesartan on
coronary artery disease in patients with Diabetes Interventions and microalbuminuria and albumin excretion
type 2 diabetes: the DIAD study: Complications cohort. Arch Intern Med rate in diabetes: three randomized trials.
a randomized controlled trial. JAMA 2009; 2011;171:412420 Ann Intern Med 2009;151:1120, W3-4
301:15471555 408. Molitch ME, Steffes M, Sun W, et al.; 419. Mauer M, Zinman B, Gardiner R, et al.
398. Wackers FJ, Young LH, Inzucchi SE, et al.; Epidemiology of Diabetes Interventions Renal and retinal effects of enalapril and
Detection of Ischemia in Asymptomatic and Complications Study Group. losartan in type 1 diabetes. N Engl J Med
Diabetics Investigators. Detection of silent Development and progression of renal 2009;361:4051
myocardial ischemia in asymptomatic insufciency with and without 420. Lewis EJ, Hunsicker LG, Clarke WR,
diabetic subjects: the DIAD study. albuminuria in adults with type 1 diabetes et al.; Collaborative Study Group.
Diabetes Care 2004;27:19541961 in the Diabetes Control and Complications Renoprotective effect of the angiotensin-
399. Scognamiglio R, Negut C, Ramondo A, Trial and the Epidemiology of Diabetes receptor antagonist irbesartan in patients
Tiengo A, Avogaro A. Detection of Interventions and Complications Study. with nephropathy due to type 2 diabetes.
coronary artery disease in asymptomatic Diabetes Care 2010;33:15361543 N Engl J Med 2001;345:851860
patients with type 2 diabetes mellitus. 409. de Boer IH, Sun W, Cleary PA, et al.; DCCT/ 421. Brenner BM, Cooper ME, de Zeeuw D,
J Am Coll Cardiol 2006;47:6571 EDIC Research Group. Intensive diabetes et al.; RENAAL Study Investigators. Effects
400. Hadamitzky M, Hein F, Meyer T, et al. therapy and glomerular ltration rate in of losartan on renal and cardiovascular
Prognostic value of coronary computed type 1 diabetes. N Engl J Med 2011;365: outcomes in patients with type 2 diabetes
tomographic angiography in diabetic 23662376 and nephropathy. N Engl J Med 2001;345:
patients without known coronary artery 410. National Kidney Foundation. KDOQI 861869
disease. Diabetes Care 2010;33:1358 clinical practice guidline for diabetes and422. Parving HH, Lehnert H, Brochner-
1363 CKD: 2012 update. Am J Kidney Dis 2012; Mortensen J, Gomis R, Andersen S, Arner
401. Elkeles RS, Godsland IF, Feher MD, et al.; 60:850886 P; Irbesartan in Patients with Type 2
PREDICT Study Group. Coronary calcium 411. Gall MA, Hougaard P, Borch-Johnsen K, Diabetes and Microalbuminuria Study
measurement improves prediction of Parving HH. Risk factors for development Group. The effect of irbesartan on the
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S75

development of diabetic nephropathy in Digestive and Kidney Diseases (NIDDK). 447. Nguyen QD, Brown DM, Marcus DM, et al.;
patients with type 2 diabetes. N Engl J Am J Kidney Dis 2003;42:617622 RISE and RIDE Research Group.
Med 2001;345:870878 434. Levey AS, Coresh J, Balk E, et al.; National Ranibizumab for diabetic macular edema:
423. Pepine CJ, Handberg EM, Cooper-DeHoff results from 2 phase III randomized trials:
Kidney Foundation. National Kidney
RM, et al.; INVEST Investigators. A calcium RISE and RIDE. Ophthalmology 2012;119:
Foundation practice guidelines for chronic
789801
antagonist vs a non-calcium antagonist kidney disease: evaluation, classication,
hypertension treatment strategy for and stratication. Ann Intern Med 2003; 448. Pearson PA, Comstock TL, Ip M, et al.
patients with coronary artery disease. The 139:137147 Fluocinolone acetonide intravitreal
International Verapamil-Trandolapril implant for diabetic macular edema:
435. Kramer H, Molitch ME. Screening for
Study (INVEST): a randomized controlled a 3-year multicenter, randomized,
kidney disease in adults with diabetes.
trial. JAMA 2003;290:28052816 controlled clinical trial. Ophthalmology
Diabetes Care 2005;28:18131816
2011;118:15801587
424. Mogensen CE, Neldam S, Tikkanen I, et al.
436. Kramer HJ, Nguyen QD, Curhan G, Hsu CY.
Randomised controlled trial of dual 449. Chew EY, Ambrosius WT. Update of the
Renal insufciency in the absence of
blockade of renin-angiotensin system in ACCORD Eye Study. N Engl J Med 2011;
albuminuria and retinopathy among
patients with hypertension, 364:188189
adults with type 2 diabetes mellitus. JAMA
microalbuminuria, and non-insulin 450. Keech AC, Mitchell P, Summanen PA,
2003;289:32733277
dependent diabetes: the candesartan and et al.; FIELD study investigators. Effect of
lisinopril microalbuminuria (CALM) study. 437. Levey AS, Bosch JP, Lewis JB, Greene T,
fenobrate on the need for laser
BMJ 2000;321:14401444 Rogers N, Roth D; Modication of Diet in
treatment for diabetic retinopathy (FIELD
Renal Disease Study Group. A more
425. Schjoedt KJ, Jacobsen P, Rossing K, study): a randomised controlled trial.
accurate method to estimate glomerular
Boomsma F, Parving HH. Dual blockade of Lancet 2007;370:16871697
ltration rate from serum creatinine:
the renin-angiotensin-aldosterone system 451. Hooper P, Boucher MC, Cruess A, et al.
a new prediction equation. Ann Intern
in diabetic nephropathy: the role of Canadian Ophthalmological Society
Med 1999;130:461470
aldosterone. Horm Metab Res 2005;37 evidence-based clinical practice
(Suppl. 1):48 438. Levinsky NG. Specialist evaluation in
guidelines for the management of diabetic
chronic kidney disease: too little, too late.
426. Schjoedt KJ, Rossing K, Juhl TR, et al. retinopathy. Can J Ophthalmol 2012;47
Ann Intern Med 2002;137:542543
Benecial impact of spironolactone in (Suppl.):S1S30, S31S54
diabetic nephropathy. Kidney Int 2005;68: 439. Klein R. Hyperglycemia and microvascular
452. Agardh E, Tababat-Khani P. Adopting
28292836 and macrovascular disease in diabetes.
3-year screening intervals for sight-
Diabetes Care 1995;18:258268
427. Parving HH, Persson F, Lewis JB, Lewis EJ, threatening retinal vascular lesions in type
Hollenberg NK; AVOID Study 440. Estacio RO, McFarling E, Biggerstaff S, 2 diabetic subjects without retinopathy.
Investigators. Aliskiren combined with Jeffers BW, Johnson D, Schrier RW. Overt Diabetes Care 2011;34:13181319
losartan in type 2 diabetes and albuminuria predicts diabetic retinopathy 453. Ahmed J, Ward TP, Bursell SE, Aiello LM,
nephropathy. N Engl J Med 2008;358: in Hispanics with NIDDM. Am J Kidney Dis Cavallerano JD, Vigersky RA. The
24332446 1998;31:947953 sensitivity and specicity of nonmydriatic
428. Yusuf S, Teo KK, Pogue J, et al.; ONTARGET 441. Leske MC, Wu SY, Hennis A, et al.; digital stereoscopic retinal imaging in
Investigators. Telmisartan, ramipril, or Barbados Eye Study Group. detecting diabetic retinopathy. Diabetes
both in patients at high risk for vascular Hyperglycemia, blood pressure, and the Care 2006;29:22052209
events. N Engl J Med 2008;358:15471559 9-year incidence of diabetic retinopathy: 454. Spallone V, Ziegler D, Freeman R, et al.;
the Barbados Eye Studies. Ophthalmology Toronto Consensus Panel on Diabetic
429. Pijls LT, de Vries H, Donker AJ, van Eijk JT.
2005;112:799805 Neuropathy. Cardiovascular autonomic
The effect of protein restriction on
albuminuria in patients with type 2 442. Chew EY, Ambrosius WT, Davis MD, et al.; neuropathy in diabetes: clinical impact,
diabetes mellitus: a randomized trial. ACCORD Study Group; ACCORD Eye assessment, diagnosis, and management.
Nephrol Dial Transplant 1999;14:1445 Study Group. Effects of medical Diabetes Metab Res Rev 2011;27:639
1453 therapies on retinopathy progression in 653
type 2 diabetes. N Engl J Med 2010;363: 455. Bril V, England J, Franklin GM, et al.;
430. Pedrini MT, Levey AS, Lau J, Chalmers TC,
233244 American Academy of Neurology;
Wang PH. The effect of dietary protein
restriction on the progression of diabetic 443. Fong DS, Aiello LP, Ferris FL 3rd, Klein R. American Association of Neuromuscular
and nondiabetic renal diseases: a meta- Diabetic retinopathy. Diabetes Care 2004; and Electrodiagnostic Medicine; American
analysis. Ann Intern Med 1996;124:627 27:25402553 Academy of Physical Medicine and
632 Rehabilitation. Evidence-based guideline:
444. Diabetes Control and Complications
treatment of painful diabetic neuropathy:
431. Hansen HP, Tauber-Lassen E, Jensen BR, Trial Research Group. Effect of
report of the American Academy of
Parving HH. Effect of dietary protein pregnancy on microvascular
Neurology, the American Association of
restriction on prognosis in patients with complications in the diabetes control and
Neuromuscular and Electrodiagnostic
diabetic nephropathy. Kidney Int 2002;62: complications trial. Diabetes Care 2000;
Medicine, and the American Academy of
220228 23:10841091
Physical Medicine and Rehabilitation
432. Kasiske BL, Lakatua JD, Ma JZ, Louis TA. 445. The Diabetic Retinopathy Study Research [published correction appears in
A meta-analysis of the effects of dietary Group. Preliminary report on effects of Neurology 2011;77:603]. Neurology 2011;
protein restriction on the rate of decline in photocoagulation therapy. Am J 76:17581765
renal function. Am J Kidney Dis 1998;31: Ophthalmol 1976;81:383396
456. Pop-Busui R, Lu J, Brooks MM, et al.
954961 446. ETDRS. Photocoagulation for diabetic Impact of glycemic control strategies on
433. Eknoyan G, Hostetter T, Bakris GL, et al. macular edema. Early Treatment Diabetic the progression of diabetic peripheral
Proteinuria and other markers of chronic Retinopathy Study report number 1. Early neuropathy in the Bypass Angioplasty
kidney disease: a position statement of Treatment Diabetic Retinopathy Study Revascularization Investigation 2 Diabetes
the National Kidney Foundation (NKF) and research group. Arch Ophthalmol 1985; (BARI 2D) cohort. Diabetes Care 2013;36:
the National Institute of Diabetes and 103:17961806 32083215
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S76 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

457. Herman WH, Pop-Busui R, Braffett BH, cross-sectional survey. Diabetes Metab 478. Li C, Ford ES, Zhao G, Croft JB, Balluz LS,
et al.; DCCT/EDIC Research Group. Use of Syndr Obes 2013;6:7992 Mokdad AH. Prevalence of self-reported
the Michigan Neuropathy Screening clinically diagnosed sleep apnea according
467. Snedecor SJ, Sudharshan L, Cappelleri JC,
Instrument as a measure of distal to obesity status in men and women:
Sadosky A, Mehta S, Botteman M.
symmetrical peripheral neuropathy in National Health and Nutrition
Systematic review and meta-analysis of
type 1 diabetes: results from the Diabetes Examination Survey, 20052006. Prev
pharmacological therapies for painful
Control and Complications Trial/ Med 2010;51:1823
diabetic peripheral neuropathy. Pain
Epidemiology of Diabetes Interventions 479. West SD, Nicoll DJ, Stradling JR.
Pract. 28 March 2013 [Epub ahead of
and Complications. Diabet Med 2012;29: Prevalence of obstructive sleep apnoea in
print]
937944 men with type 2 diabetes. Thorax 2006;61:
468. Boulton AJ, Vinik AI, Arezzo JC, et al.;
458. Wile DJ, Toth C. Association of metformin, 945950
American Diabetes Association. Diabetic
elevated homocysteine, and 480. Foster GD, Sanders MH, Millman R, et al.;
neuropathies: a statement by the
methylmalonic acid levels and clinically Sleep AHEAD Research Group. Obstructive
American Diabetes Association. Diabetes
worsened diabetic peripheral neuropathy. sleep apnea among obese patients with
Care 2005;28:956962
Diabetes Care 2010;33:156161 type 2 diabetes. Diabetes Care 2009;32:
469. Gaede P, Vedel P, Larsen N, Jensen GV,
459. Freeman R. Not all neuropathy in diabetes 10171019
Parving HH, Pedersen O. Multifactorial
is of diabetic etiology: differential 481. Shaw JE, Punjabi NM, Wilding JP, Alberti
intervention and cardiovascular disease in
diagnosis of diabetic neuropathy. Curr KG, Zimmet PZ; International Diabetes
patients with type 2 diabetes. N Engl J
Diab Rep 2009;9:423431 Federation Taskforce on Epidemiology
Med 2003;348:383393
460. Spallone V, Bellavere F, Scionti L, et al.; and Prevention. Sleep-disordered
470. Boulton AJ, Armstrong DG, Albert SF,
Diabetic Neuropathy Study Group of the breathing and type 2 diabetes: a report
et al.; American Diabetes Association;
Italian Society of Diabetology. from the International Diabetes
American Association of Clinical
Recommendations for the use of Federation Taskforce on Epidemiology
Endocrinologists. Comprehensive foot
cardiovascular tests in diagnosing diabetic and Prevention. Diabetes Res Clin Pract
examination and risk assessment: a report
autonomic neuropathy. Nutr Metab 2008;81:212
of the task force of the foot care interest
Cardiovasc Dis 2011;21:6978 482. El-Serag HB, Tran T, Everhart JE. Diabetes
group of the American Diabetes Association,
461. Diabetes Control and Complications Trial with endorsement by the American increases the risk of chronic liver disease
(DCCT) Research Group. Effect of intensive Association of Clinical Endocrinologists. and hepatocellular carcinoma.
diabetes treatment on nerve conduction Diabetes Care 2008;31:16791685 Gastroenterology 2004;126:460468
in the Diabetes Control and Complications 483. American Gastroenterological
471. American Diabetes Association.
Trial. Ann Neurol 1995;38:869880 Association. American
Peripheral arterial disease in people with
462. CDC Study Group. The effect of intensive diabetes. Diabetes Care 2003;26:3333 Gastroenterological Association medical
diabetes therapy on measures of 3341 position statement: nonalcoholic fatty
autonomic nervous system function in liver disease. Gastroenterology 2002;123:
472. Lipsky BA, Berendt AR, Cornia PB, et al.; 17021704
the Diabetes Control and Complications
Infectious Diseases Society of America.
Trial (DCCT). Diabetologia 1998;41:416 484. Suh S, Kim KW. Diabetes and cancer: is
2012 Infectious Diseases Society of
423 diabetes causally related to cancer?
America clinical practice guideline for the
463. Albers JW, Herman WH, Pop-Busui R, diagnosis and treatment of diabetic foot Diabetes Metab J 2011;35:193198
et al.; Diabetes Control and Complications infections. Clin Infect Dis 2012;54:e132 485. International Diabetes Federation. Oral
Trial /Epidemiology of Diabetes e173 Health for People with Diabetes. Brussels,
Interventions and Complications Research International Diabetes Federation, 2009
473. Selvin E, Coresh J, Brancati FL. The burden
Group. Effect of prior intensive insulin
and treatment of diabetes in elderly 486. Giovannucci E, Harlan DM, Archer MC,
treatment during the Diabetes Control
individuals in the U.S. Diabetes Care 2006; et al. Diabetes and cancer: a consensus
and Complications Trial (DCCT) on
29:24152419 report. Diabetes Care 2010;33:16741685
peripheral neuropathy in type 1 diabetes
during the Epidemiology of Diabetes 474. Grant RW, Ashburner JM, Hong CS, Chang 487. Janghorbani M, Van Dam RM, Willett WC,
Interventions and Complications (EDIC) Y, Barry MJ, Atlas SJ. Dening patient Hu FB. Systematic review of type 1 and
Study. Diabetes Care 2010;33:10901096 complexity from the primary care type 2 diabetes mellitus and risk of
physicians perspective: a cohort study fracture. Am J Epidemiol 2007;166:495
464. Pop-Busui R, Low PA, Waberski BH, et al.;
[published correction appears in Ann 505
DCCT/EDIC Research Group. Effects of
Intern Med 2012;157:152]. Ann Intern
prior intensive insulin therapy on cardiac 488. Vestergaard P. Discrepancies in bone
Med 2011;155:797804
autonomic nervous system function in mineral density and fracture risk in
type 1 diabetes mellitus: the Diabetes 475. Tinetti ME, Fried TR, Boyd CM. Designing patients with type 1 and type 2
Control and Complications Trial/ health care for the most common chronic diabetesda meta-analysis. Osteoporos
Epidemiology of Diabetes Interventions conditiondmultimorbidity. JAMA 2012; Int 2007;18:427444
and Complications study (DCCT/EDIC). 307:24932494
489. Schwartz AV, Vittinghoff E, Bauer DC,
Circulation 2009;119:28862893 476. Sudore RL, Karter AJ, Huang ES, et al. et al.; Study of Osteoporotic Fractures
465. Callaghan BC, Little AA, Feldman EL, Symptom burden of adults with type 2 (SOF) Research Group; Osteoporotic
Hughes RA. Enhanced glucose control for diabetes across the disease course: Fractures in Men (MrOS) Research Group;
preventing and treating diabetic Diabetes & Aging Study. J Gen Intern Med Health, Aging, and Body Composition
neuropathy. Cochrane Database Syst Rev 2012;27:16741681 (Health ABC) Research Group. Association
2012;(6):CD007543 477. Borgnakke WS, Ylostalo PV, Taylor GW, of BMD and FRAX score with risk of
466. Sadosky A, Schaefer C, Mann R, et al. Genco RJ. Effect of periodontal disease fracture in older adults with type 2
Burden of illness associated with painful on diabetes: systematic review of diabetes. JAMA 2011;305:21842192
diabetic peripheral neuropathy among epidemiologic observational evidence. 490. Cukierman T, Gerstein HC, Williamson JD.
adults seeking treatment in the US: results J Periodontol 2013;84(Suppl.):S135 Cognitive decline and dementia in
from a retrospective chart review and S152 diabetesdsystematic overview of
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S77

prospective observational studies. 503. Nimri R, Weintrob N, Benzaquen H, Ofan the Council on Cardiovascular Nursing.
Diabetologia 2005;48:24602469 R, Fayman G, Phillip M. Insulin pump Circulation 2007;115:19481967
491. Biessels GJ, Staekenborg S, Brunner E, therapy in youth with type 1 diabetes: 512. Salo P, Viikari J, Hamalainen M, et al.
Brayne C, Scheltens P. Risk of dementia in a retrospective paired study. Pediatrics Serum cholesterol ester fatty acids in
diabetes mellitus: a systematic review. 2006;117:21262131 7- and 13-month-old children in a
Lancet Neurol 2006;5:6474 504. Doyle EA, Weinzimer SA, Steffen AT, prospective randomized trial of a low-
492. Ohara T, Doi Y, Ninomiya T, et al. Glucose Ahern JA, Vincent M, Tamborlane WV. A saturated fat, low-cholesterol diet: the
tolerance status and risk of dementia in randomized, prospective trial comparing STRIP baby project. Special Turku coronary
the community: the Hisayama study. the efcacy of continuous subcutaneous Risk factor Intervention Project for
Neurology 2011;77:11261134 insulin infusion with multiple daily children. Acta Paediatr 1999;88:505512
injections using insulin glargine. Diabetes 513. The Dietary Intervention Study in Children
493. Launer LJ, Miller ME, Williamson JD, et al.; Care 2004;27:15541558
ACCORD MIND investigators. Effects of (DISC); Writing Group for the DISC
intensive glucose lowering on brain 505. Perantie DC, Wu J, Koller JM, et al. Collaborative Research Group. Efcacy
structure and function in people with type Regional brain volume differences and safety of lowering dietary intake of fat
2 diabetes (ACCORD MIND): a randomised associated with hyperglycemia and severe and cholesterol in children with elevated
open-label substudy. Lancet Neurol 2011; hypoglycemia in youth with type 1 low-density lipoprotein cholesterol. JAMA
10:969977 diabetes. Diabetes Care 2007;30:2331 1995;273:14291435
2337 514. Maahs DM, Dabelea D, DAgostino RB Jr,
494. Dhindsa S, Miller MG, McWhirter CL, et al.
Testosterone concentrations in diabetic 506. Daniels M, DuBose SN, Maahs DM, et al.; et al.; SEARCH for Diabetes in Youth Study.
and nondiabetic obese men. Diabetes T1D Exchange Clinic Network. Factors Glucose control predicts 2-year change in
Care 2010;33:11861192 associated with microalbuminuria in 7,549 lipid prole in youth with type 1 diabetes.
children and adolescents with type 1 J Pediatr 2013;162:101107.e1
495. Bhasin S, Cunningham GR, Hayes FJ, et al.; diabetes in the T1D Exchange clinic
Task Force, Endocrine Society. 515. McCrindle BW, Ose L, Marais AD.
registry. Diabetes Care 2013;36:2639 Efcacy and safety of atorvastatin in
Testosterone therapy in men with 2645
androgen deciency syndromes: an children and adolescents with familial
Endocrine Society clinical practice 507. Hortenhuber T, Rami-Mehar B, Satler M, hypercholesterolemia or severe
guideline. J Clin Endocrinol Metab 2010; et al. Endothelial progenitor cells are hyperlipidemia: a multicenter,
95:25362559 related to glycemic control in children randomized, placebo-controlled trial.
with type 1 diabetes over time. Diabetes J Pediatr 2003;143:7480
496. Khader YS, Dauod AS, El-Qaderi SS,
Care 2013;36:16471653 516. de Jongh S, Lilien MR, opt Roodt J, Stroes
Alkafajei A, Batayha WQ. Periodontal
status of diabetics compared with 508. Haller MJ, Samyn M, Nichols WW, et al. ES, Bakker HD, Kastelein JJ. Early statin
nondiabetics: a meta-analysis. J Diabetes Radial artery tonometry demonstrates therapy restores endothelial function in
Complications 2006;20:5968 arterial stiffness in children with type 1 children with familial
diabetes. Diabetes Care 2004;27:2911 hypercholesterolemia. J Am Coll Cardiol
497. Bainbridge KE, Hoffman HJ, Cowie CC. 2002;40:21172121
2917
Diabetes and hearing impairment in the
United States: audiometric evidence from 509. Orchard TJ, Forrest KY, Kuller LH, Becker 517. Wiegman A, Hutten BA, de Groot E,
the National Health and Nutrition DJ; Pittsburgh Epidemiology of Diabetes et al. Efcacy and safety of statin
Examination Survey, 1999 to 2004. Ann Complications Study. Lipid and blood therapy in children with familial
Intern Med 2008;149:110 pressure treatment goals for type 1 hypercholesterolemia: a randomized
diabetes: 10-year incidence data from the controlled trial. JAMA 2004;292:331337
498. Silverstein J, Klingensmith G, Copeland KC,
Pittsburgh Epidemiology of Diabetes 518. Cho YH, Craig ME, Hing S, et al.
et al.; American Diabetes Association.
Complications Study. Diabetes Care 2001; Microvascular complications assessment
Care of children and adolescents with type
24:10531059 in adolescents with 2- to 5-yr duration of
1 diabetes: a statement of the American
Diabetes Association. Diabetes Care 2005; 510. Kavey RE, Allada V, Daniels SR, et al. type 1 diabetes from 1990 to 2006. Pediatr
28:186212 Cardiovascular risk reduction in high-risk Diabetes 2011;12:682689
499. Wysocki T, Harris MA, Mauras N, et al. pediatric patients: a scientic statement 519. Holmes GK. Screening for coeliac disease
Absence of adverse effects of severe from the American Heart Association in type 1 diabetes. Arch Dis Child 2002;87:
hypoglycemia on cognitive function in Expert Panel on Population and 495498
school-aged children with diabetes over 18 Prevention Science; the Councils on
Cardiovascular Disease in the Young, 520. Rewers M, Liu E, Simmons J, Redondo MJ,
months. Diabetes Care 2003;26:11001105 Hoffenberg EJ. Celiac disease associated
Epidemiology and Prevention, Nutrition,
500. Blasetti A, Chiuri RM, Tocco AM, et al. Physical Activity and Metabolism, High with type 1 diabetes mellitus. Endocrinol
The effect of recurrent severe Blood Pressure Research, Cardiovascular Metab Clin North Am 2004;33:197214
hypoglycemia on cognitive performance Nursing, and the Kidney in Heart Disease; 521. Husby S, Koletzko S, Korponay-Szabo IR,
in children with type 1 diabetes: a meta- and the Interdisciplinary Working Group et al.; ESPGHAN Working Group on Coeliac
analysis. J Child Neurol 2011;26:1383 on Quality of Care and Outcomes Disease Diagnosis; ESPGHAN
1391 Research: endorsed by the American Gastroenterology Committee; European
501. Cooper MN, OConnell SM, Davis EA, Jones Academy of Pediatrics. Circulation 2006; Society for Pediatric Gastroenterology,
TW. A population-based study of risk 114:27102738 Hepatology, and Nutrition. European
factors for severe hypoglycaemia in a 511. McCrindle BW, Urbina EM, Dennison BA, Society for Pediatric Gastroenterology,
contemporary cohort of childhood-onset et al. Drug therapy of high-risk lipid Hepatology, and Nutrition guidelines for
type 1 diabetes. Diabetologia 2013;56: abnormalities in children and the diagnosis of coeliac disease. J Pediatr
21642170 adolescents: a scientic statement from Gastroenterol Nutr 2012;54:136160
502. Zuijdwijk CS, Cuerden M, Mahmud FH. the American Heart Association 522. Kurppa K, Ashorn M, Iltanen S, et al.
Social determinants of health on glycemic Atherosclerosis, Hypertension, and Celiac disease without villous atrophy
control in pediatric type 1 diabetes. Obesity in Youth Committee, Council of in children: a prospective study. J Pediatr
J Pediatr 2013;162:730735 Cardiovascular Disease in the Young, with 2010;157:373380.e1
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S78 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

523. Abid N, McGlone O, Cardwell C, McCallion psychological course of diabetes from diabetes: current trends in prevalence,
W, Carson D. Clinical and metabolic effects adolescence to young adulthood: incidence, and mortality. Diabetes Care
of gluten free diet in children with type 1 a longitudinal cohort study. Diabetes Care 2009;32:16261631
diabetes and coeliac disease. Pediatr 2001;24:15361540 547. Onady GM, Stol A. Insulin and oral agents
Diabetes 2011;12:322325
534. Laing SP, Jones ME, Swerdlow AJ, Burden for managing cystic brosis-related
524. Roldan MB, Alonso M, Barrio R. Thyroid AC, Gatling W. Psychosocial and diabetes. Cochrane Database Syst Rev
autoimmunity in children and adolescents socioeconomic risk factors for premature 2013;(7):CD004730
with Type 1 diabetes mellitus. Diabetes death in young people with type 1 diabetes. 548. Moran A, Brunzell C, Cohen RC, et al.;
Nutr Metab 1999;12:2731 Diabetes Care 2005;28:16181623 CFRD Guidelines Committee. Clinical care
525. Triolo TM, Armstrong TK, McFann K, et al. 535. Eppens MC, Craig ME, Cusumano J, et al. guidelines for cystic brosis-related
Additional autoimmune disease found in Prevalence of diabetes complications in diabetes: a position statement of the
33% of patients at type 1 diabetes onset. adolescents with type 2 compared with American Diabetes Association and a
Diabetes Care 2011;34:12111213 type 1 diabetes. Diabetes Care 2006;29: clinical practice guideline of the Cystic
526. Kordonouri O, Deiss D, Danne T, Dorow A, 13001306 Fibrosis Foundation, endorsed by the
Bassir C, Gruters-Kieslich A. Predictivity of Pediatric Endocrine Society. Diabetes Care
536. Hattersley A, Bruining J, Shield J, Njolstad
thyroid autoantibodies for the 2010;33:26972708
P, Donaghue KC. The diagnosis and
development of thyroid disorders in management of monogenic diabetes in 549. van den Berghe G, Wouters P, Weekers F,
children and adolescents with type 1 children and adolescents. Pediatr et al. Intensive insulin therapy in critically
diabetes. Diabet Med 2002;19:518521 Diabetes 2009;10(Suppl. 12):3342 ill patients. N Engl J Med 2001;345:1359
527. Mohn A, Di Michele S, Di Luzio R, Tumini S, 1367
537. Kitzmiller JL, Wallerstein R, Correa A, Kwan
Chiarelli F. The effect of subclinical S. Preconception care for women with 550. Malmberg K, Norhammar A, Wedel H,
hypothyroidism on metabolic control in diabetes and prevention of major Ryden L. Glycometabolic state at
children and adolescents with type 1 congenital malformations. Birth Defects admission: important risk marker of
diabetes mellitus. Diabet Med 2002;19: Res A Clin Mol Teratol 2010;88:791803 mortality in conventionally treated
7073 patients with diabetes mellitus and acute
538. Charron-Prochownik D, Sereika SM, myocardial infarction: long-term results
528. Chase HP, Garg SK, Cockerham RS, Wilcox Becker D, et al. Long-term effects of the
WD, Walravens PA. Thyroid hormone from the Diabetes and Insulin-Glucose
booster-enhanced READY-Girls Infusion in Acute Myocardial Infarction
replacement and growth of children with preconception counseling program on
subclinical hypothyroidism and diabetes. (DIGAMI) study. Circulation 1999;99:
intentions and behaviors for family 26262632
Diabet Med 1990;7:299303 planning in teens with diabetes. Diabetes
529. American Diabetes Association. Diabetes Care 2013;36:38703874 551. Clement S, Braithwaite SS, Magee MF,
care in the school and day care setting. et al.; American Diabetes Association
539. Cooper WO, Hernandez-Diaz S, Arbogast Diabetes in Hospitals Writing Committee.
Diabetes Care 2014;37(Suppl. 1):S91S96 PG, et al. Major congenital malformations Management of diabetes and
530. Arnett JJ. Emerging adulthood. A theory of after rst-trimester exposure to ACE hyperglycemia in hospitals [published
development from the late teens through inhibitors. N Engl J Med 2006;354:2443 correction appears in Diabetes Care 2004;
the twenties. Am Psychol 2000;55:469 2451 27:856 and 2044;27:155]. Diabetes Care
480 2004;27:553591
540. American Diabetes Association.
531. Weissberg-Benchell J, Wolpert H, Preconception care of women with 552. Wiener RS, Wiener DC, Larson RJ. Benets
Anderson BJ. Transitioning from pediatric diabetes. Diabetes Care 2004;27(Suppl. and risks of tight glucose control in
to adult care: a new approach to the post- 1):S76S78 critically ill adults: a meta-analysis. JAMA
adolescent young person with type 1 2008;300:933944
541. Kirkman MS, Briscoe VJ, Clark N, et al.
diabetes. Diabetes Care 2007;30:2441
Diabetes in older adults. Diabetes Care 553. Brunkhorst FM, Engel C, Bloos F, et al.;
2446
2012;35:26502664 German Competence Network Sepsis
532. Peters A, Laffel L, the American Diabetes (SepNet). Intensive insulin therapy and
542. Curb JD, Pressel SL, Cutler JA, et al.;
Association Transitions Working Group. pentastarch resuscitation in severe sepsis.
Systolic Hypertension in the Elderly
Diabetes care for emerging adults: N Engl J Med 2008;358:125139
Program Cooperative Research Group.
recommendations for transition from
Effect of diuretic-based antihypertensive 554. Finfer S, Chittock DR, Su SY, et al.; NICE-
pediatric to adult diabetes care systems:
treatment on cardiovascular disease risk SUGAR Study Investigators. Intensive
a position statement of the American
in older diabetic patients with isolated versus conventional glucose control in
Diabetes Association, with representation
by the American College of Osteopathic systolic hypertension. JAMA 1996;276: critically ill patients. N Engl J Med 2009;
Family Physicians, the American Academy 18861892 360:12831297
of Pediatrics, the American Association of 543. Beckett NS, Peters R, Fletcher AE, et al.; 555. Krinsley JS, Grover A. Severe
Clinical Endocrinologists, the American HYVET Study Group. Treatment of hypoglycemia in critically ill patients: risk
Osteopathic Association, the Centers for hypertension in patients 80 years of age or factors and outcomes. Crit Care Med
Disease Control and Prevention, Children older. N Engl J Med 2008;358:18871898 2007;35:22622267
with Diabetes, The Endocrine Society, the
544. Kern AS, Prestridge AL. Improving 556. Van den Berghe G, Wilmer A, Hermans G,
International Society for Pediatric and
screening for cystic brosis-related et al. Intensive insulin therapy in the medical
Adolescent Diabetes, Juvenile Diabetes
diabetes at a pediatric cystic brosis ICU. N Engl J Med 2006;354:449461
Research Foundation International, the
program. Pediatrics 2013;132:e512e518
National Diabetes Education Program, and 557. Griesdale DE, de Souza RJ, van Dam RM,
the Pediatric Endocrine Society (formerly 545. Waugh N, Royle P, Craigie I, et al. et al. Intensive insulin therapy and
Lawson Wilkins Pediatric Endocrine Screening for cystic brosis-related mortality among critically ill patients:
Society). Diabetes Care 2011;34:2477 diabetes: a systematic review. Health a meta-analysis including NICE-SUGAR
2485 Technol Assess 2012;16:iiiiv, 1179 study data. CMAJ 2009;180:821827
533. Bryden KS, Peveler RC, Stein A, Neil A, 546. Moran A, Dunitz J, Nathan B, Saeed A, 558. Saudek CD, Herman WH, Sacks DB,
Mayou RA, Dunger DB. Clinical and Holme B, Thomas W. Cystic brosis-related Bergenstal RM, Edelman D, Davidson MB.
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
care.diabetesjournals.org Position Statement S79

A new look at screening and diagnosing hospitalized patients. Diabetes Care 2010; 582. Agency for Healthcare Research and
diabetes mellitus. J Clin Endocrinol Metab 33:739741 Quality. Adverse Events after hospital
2008;93:24472453 570. Schnipper JL, Liang CL, Ndumele CD, discharge [Internet], 2010. Available from
559. Cryer PE, Davis SN, Shamoon H. Pendergrass ML. Effects of a computerized http://psnet.ahrq.gov/primer.aspx?
Hypoglycemia in diabetes. Diabetes Care order set on the inpatient management of primerID511
2003;26:19021912 hyperglycemia: a cluster-randomized 583. American Diabetes Association. Diabetes
controlled trial. Endocr Pract 2010;16: and employment. Diabetes Care 2014;37
560. Moghissi ES, Korytkowski MT, DiNardo M,
209218 (Suppl. 1):S112S117
et al.; American Association of Clinical
Endocrinologists; American Diabetes 571. Wexler DJ, Shrader P, Burns SM, Cagliero 584. American Diabetes Association. Diabetes
Association. American Association of E. Effectiveness of a computerized insulin and driving. Diabetes Care 2014;37
Clinical Endocrinologists and American order template in general medical (Suppl. 1):S97S103
Diabetes Association consensus inpatients with type 2 diabetes: a cluster
585. American Diabetes Association. Diabetes
statement on inpatient glycemic control. randomized trial. Diabetes Care 2010;33:
management in correctional institutions.
Diabetes Care 2009;32:11191131 21812183
Diabetes Care 2014;37(Suppl. 1):S104S111
561. Hsu CW, Sun SF, Lin SL, Huang HH, Wong 572. Furnary AP, Braithwaite SS. Effects of
586. Hoerger TJ, Segel JE, Gregg EW, Saaddine
KF. Moderate glucose control results in outcome on in-hospital transition from
JB. Is glycemic control improving in U.S.
less negative nitrogen balances in medical intravenous insulin infusion to
adults?Diabetes Care 2008;31:8186
intensive care unit patients: subcutaneous therapy. Am J Cardiol 2006;
a randomized, controlled study. Crit Care 98:557564 587. Wang J, Geiss LS, Cheng YJ, et al. Long-
2012;16:R56 term and recent progress in blood
573. Schafer RG, Bohannon B, Franz MJ, et al.;
pressure levels among U.S. adults with
562. Umpierrez GE, Hellman R, Korytkowski American Diabetes Association. Diabetes
nutrition recommendations for health diagnosed diabetes, 19882008. Diabetes
MT, et al.; Endocrine Society.
care institutions. Diabetes Care 2004;27 Care 2011;34:15791581
Management of hyperglycemia in
hospitalized patients in non-critical care (Suppl. 1):S55S57 588. Kerr EA, Heisler M, Krein SL, et al. Beyond
setting: an Endocrine Society clinical 574. Curll M, Dinardo M, Noschese M, comorbidity counts: how do comorbidity
practice guideline. J Clin Endocrinol Metab Korytkowski MT. Menu selection, type and severity inuence diabetes
2012;97:1638 glycaemic control and satisfaction with patients treatment priorities and self-
standard and patient-controlled management? J Gen Intern Med 2007;22:
563. Bernard JB, Munoz C, Harper J, Muriello
consistent carbohydrate meal plans in 16351640
M, Rico E, Baldwin D. Treatment of
inpatient hyperglycemia beginning in the hospitalised patients with diabetes. Qual 589. Fernandez A, Schillinger D, Warton EM,
emergency department: a randomized Saf Health Care 2010;19:355359 et al. Language barriers, physician-patient
trial using insulins aspart and detemir 575. Korytkowski MT, Salata RJ, Koerbel GL, language concordance, and glycemic
compared with usual care. J Hosp Med et al. Insulin therapy and glycemic control control among insured Latinos with
2011;6:279284 in hospitalized patients with diabetes diabetes: the Diabetes Study of Northern
during enteral nutrition therapy: California (DISTANCE). J Gen Intern Med
564. Czosnowski QA, Swanson JM, Lobo BL,
a randomized controlled clinical trial. 2011;26:170176
Broyles JE, Deaton PR, Finch CK.
Evaluation of glycemic control following Diabetes Care 2009;32:594596 590. Stellefson M, Dipnarine K, Stopka C. The
discontinuation of an intensive insulin 576. Umpierrez GE. Basal versus sliding-scale chronic care model and diabetes
protocol. J Hosp Med 2009;4:2834 regular insulin in hospitalized patients with management in US primary care settings:
hyperglycemia during enteral nutrition a systematic review. Prev Chronic Dis
565. Shomali MI, Herr DL, Hill PC, Pehlivanova
therapy. Diabetes Care 2009;32:751753 2013;10:E26
M, Sharretts JM, Magee MF. Conversion
from intravenous insulin to subcutaneous 577. Klonoff DC, Perz JF. Assisted monitoring of 591. Coleman K, Austin BT, Brach C, Wagner EH.
insulin after cardiovascular surgery: blood glucose: special safety needs for a Evidence on the chronic care model in the
transition to target study. Diabetes new paradigm in testing glucose. J new millennium. Health Aff (Millwood)
Technol Ther 2011;13:121126 Diabetes Sci Tech 2010;4:10271031 2009;28:7585
566. Baldwin D, Zander J, Munoz C, et al. A 578. DOrazio P, Burnett RW, Fogh-Andersen N, 592. Parchman ML, Zeber JE, Romero RR, Pugh
randomized trial of two weight-based et al.; International Federation of Clinical JA. Risk of coronary artery disease in type
doses of insulin glargine and glulisine in Chemistry Scientic Division Working 2 diabetes and the delivery of care
hospitalized subjects with type 2 diabetes Group on Selective Electrodes and Point of consistent with the chronic care model in
and renal insufciency. Diabetes Care Care Testing. Approved IFCC primary care settings: a STARNet study.
2012;35:19701974 recommendation on reporting results for Med Care 2007;45:11291134
567. Draznin B, Gilden J, Golden SH, et al.; blood glucose (abbreviated). Clin Chem 593. Davidson MB. How our current medical
PRIDE investigators. Pathways to quality 2005;51:15731576 care system fails people with diabetes:
inpatient management of hyperglycemia 579. Dungan K, Chapman J, Braithwaite SS, lack of timely, appropriate clinical
and diabetes: a call to action. Diabetes Buse J. Glucose measurement: decisions. Diabetes Care 2009;32:370372
Care 2013;36:18071814 confounding issues in setting targets for 594. Grant RW, Pabon-Nau L, Ross KM, Youatt
568. Umpierrez GE, Smiley D, Jacobs S, et al. inpatient management. Diabetes Care EJ, Pandiscio JC, Park ER. Diabetes oral
Randomized study of basal-bolus insulin 2007;30:403409 medication initiation and intensication:
therapy in the inpatient management of 580. Boyd JC, Bruns DE. Quality specications patient views compared with current
patients with type 2 diabetes undergoing for glucose meters: assessment by treatment guidelines. Diabetes Educ 2011;
general surgery (RABBIT 2 surgery). simulation modeling of errors in insulin 37:7884
Diabetes Care 2011;34:256261 dose. Clin Chem 2001;47:209214 595. Schillinger D, Piette J, Grumbach K, et al.
569. Pasquel FJ, Spiegelman R, McCauley M, 581. Shepperd S, McClaran J, Phillips CO, et al. Closing the loop: physician
et al. Hyperglycemia during total Discharge planning from hospital to home. communication with diabetic patients
parenteral nutrition: an important marker Cochrane Database Syst Rev 2010;(1): who have low health literacy. Arch Intern
of poor outcome and mortality in CD000313 Med 2003;163:8390
Downloaded from http://care.diabetesjournals.org/ by guest on February 3, 2014
S80 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014

596. Rosal MC, Ockene IS, Restrepo A, et al. telemonitoring in veterans with type 2 612. Feifer C, Nemeth L, Nietert PJ, et al.
Randomized trial of a literacy-sensitive, diabetes: the DiaTel randomized Different paths to high-quality care:
culturally tailored diabetes self- controlled trial. Diabetes Care 2010;33: three archetypes of top-performing
management intervention for low-income 478484 practice sites. Ann Fam Med 2007;5:233
Latinos: Latinos en Control. Diabetes Care 241
605. Berikai P, Meyer PM, Kazlauskaite R, Savoy
2011;34:838844
B, Kozik K, Fogelfeld L. Gain in patients 613. Reed M, Huang J, Graetz I, et al.
597. Osborn CY, Cavanaugh K, Wallston KA, knowledge of diabetes management Outpatient electronic health records and
et al. Health literacy explains racial targets is associated with better glycemic the clinical care and outcomes of patients
disparities in diabetes medication control. Diabetes Care 2007;30:1587 with diabetes mellitus. Ann Intern Med
adherence. J Health Commun 2011;16 1589 2012;157:482489
(Suppl. 3):268278
606. Funnell MM, Brown TL, Childs BP, et al. 614. Cebul RD, Love TE, Jain AK, Hebert CJ.
598. Rothman R, Malone R, Bryant B, Horlen C, National Standards for Diabetes Self- Electronic health records and quality of
DeWalt D, Pignone M. The relationship Management Education. Diabetes Care diabetes care. N Engl J Med 2011;365:
between literacy and glycemic control in a 2007;30:16301637 825833
diabetes disease-management program. 615. Battersby M, Von Korff M, Schaefer J, et al.
607. Klein S, Sheard NF, Pi-Sunyer X, et al.
Diabetes Educ 2004;30:263273
Weight management through lifestyle Twelve evidence-based principles for
599. OConnor PJ, Sperl-Hillen JM, Rush WA, modication for the prevention and implementing self-management support
et al. Impact of electronic health record management of type 2 diabetes: rationale in primary care. Jt Comm J Qual Patient Saf
clinical decision support on diabetes care: and strategies: a statement of the 2010;36:561570
a randomized trial. Ann Fam Med 2011;9: American Diabetes Association, the North 616. Grant RW, Wald JS, Schnipper JL, et al.
1221 American Association for the Study of Practice-linked online personal health
600. Garg AX, Adhikari NK, McDonald H, et al. Obesity, and the American Society for records for type 2 diabetes mellitus:
Effects of computerized clinical decision Clinical Nutrition. Diabetes Care 2004;27: a randomized controlled trial. Arch Intern
support systems on practitioner 20672073 Med 2008;168:17761782
performance and patient outcomes: 608. Norris SL, Zhang X, Avenell A, et al. Efcacy 617. Pullen-Smith B, Carter-Edwards L,
a systematic review. JAMA 2005;293:1223 of pharmacotherapy for weight loss in Leathers KH. Community health
1238 adults with type 2 diabetes mellitus: ambassadors: a model for engaging
601. Smith SA, Shah ND, Bryant SC, et al.; a meta-analysis. Arch Intern Med 2004; community leaders to promote better
Evidens Research Group. Chronic care model 164:13951404 health in North Carolina. J Public
and shared care in diabetes: randomized trial 609. Tricco AC, Ivers NM, Grimshaw JM, et al. Health Manag Pract 2008;14(Suppl.):
of an electronic decision support system. Effectiveness of quality improvement S73S81
Mayo Clin Proc 2008;83:747757 strategies on the management of 618. Bojadzievski T, Gabbay RA. Patient-
602. Jaffe MG, Lee GA, Young JD, Sidney S, Go diabetes: a systematic review and meta- centered medical home and diabetes.
AS. Improved blood pressure control analysis. Lancet 2012;379:22522261 Diabetes Care 2011;34:10471053
associated with a large-scale hypertension 610. OConnor PJ, Bodkin NL, Fradkin J, et al. 619. Rosenthal MB, Cutler DM, Feder J.
program. JAMA 2013;310:699705 Diabetes performance measures: current The ACO rulesdstriking the balance
603. Davidson MB, Ansari A, Karlan VJ. Effect status and future directions. Diabetes between participation and
of a nurse-directed diabetes disease Care 2011;34:16511659 transformative potential. N Engl J Med
management program on urgent care/ 611. Peikes D, Chen A, Schore J, Brown R. 2011;365:e6
emergency room visits and Effects of care coordination on 620. Washington AE, Lipstein SH. The Patient-
hospitalizations in a minority population. hospitalization, quality of care, and health Centered Outcomes Research
Diabetes Care 2007;30:224227 care expenditures among Medicare Institutedpromoting better information,
604. Stone RA, Rao RH, Sevick MA, et al. Active beneciaries: 15 randomized trials. JAMA decisions, and health. N Engl J Med 2011;
care management supported by home 2009;301:603618 365:e31

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