Standards of Medical Care in Diabetes—2017 Abridged for Primary

22 Pages·2016·0.87 MB·English

POSITION SETDATITEOMREINATL
Clinical Diabetes Papers In Press, published online December 15, 2016
Standards of Medical Care in Diabetes—2017
Abridged for Primary Care Providers
American Diabetes Association
The American Diabetes Associa- PROMOTING HEALTH AND
tion’s (ADA’s) Standards of Med- REDUCING DISPARITIES IN
ical Care in Diabetes is updated POPULATIONS
and published annually in a supple-
Recommendations
ment to the January issue of Diabetes
• Treatment plans should align
Care. The ADA’s Professional Practice
with the Chronic Care Model,
Committee, comprised of physicians,
emphasizing productive interac-
diabetes educators, registered dieti-
tions between a prepared proactive
tians, and public health experts, de-
practice team and an informed
velops the Standards. Formerly called
activated patient. A
Clinical Practice Recommendations, the
• When feasible, care systems
Standards includes the most current
should support team-based care,
evidence-based recommendations for
community involvement, patient
diagnosing and treating adults and
registries, and decision support
children with all forms of diabetes.
tools to meet patient needs. B
ADA’s grading system uses A, B, C,
or E to show the evidence level that Diabetes and Population
supports each recommendation. Health
• A—Clear evidence from well-con- Clinical practice guidelines are key
ducted, generalizable randomized to improving population health;
controlled trials that are ade- however, for optimal outcomes, di-
quately powered abetes care must be individualized
• B—Supportive evidence from for each patient. Thus, efforts to im-
well-conducted cohort studies prove population health will require
• C—Supportive evidence from a combination of systems-level and
poorly controlled or uncontrolled patient-level approaches. With such
studies an integrated approach in mind, the
• E—Expert consensus or clinical ADA highlights the importance of
This is an abridged version of the experience patient-centered care, defined as care
American Diabetes Association Position
Statement: Standards of Medical Care that is respectful of and responsive to
This is an abridged version of the
in Diabetes—2017. Diabetes Care individual patient preferences, needs,
2017;40(Suppl. 1):S1–S138. current Standards containing the
and values and ensuring that patient
The complete 2017 Standards supplement, evidence-based recommendations
values guide all clinical decisions.
including all supporting references, is most pertinent to primary care. The
available at professional.diabetes.org/
tables and figures have been renum- Care Delivery Systems
standards.
bered from the original document Despite the many advances in diabe-
DOI: 10.2337/cd16-0067
to match this version. The complete tes care, 33–49% of patients still do
©2017 by the American Diabetes Association. 2017 Standards of Care document, not meet targets for glycemic, blood
Readers may use this article as long as the work
is properly cited, the use is educational and not including all supporting references, pressure, or cholesterol control, and
for profit, and the work is not altered. See http:// is available at professional.diabetes. only 14% meet targets for all three
creativecommons.org/licenses/by-nc-nd/3.0
for details. org/standards. measures while also avoiding smok-
CLINICAL DIABETES 1
POSITION STATEMENT
Clinical Diabetes Papers In Press, published online December 15, 2016
ing. Certain segments of the popu-
TABLE. 1. Criteria for the Diagnosis of Diabetes
lation, such as young adults and pa-
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at
tients with complex comorbidities,
least 8 h.*
financial or other social hardships,
OR
and/or limited English proficiency,
face particular challenges to care. 2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test
should be performed as described by the World Health Organization,
Even after adjusting for these factors,
using a glucose load containing the equivalent of 75 g anhydrous glucose
the persistent variability in the quality
dissolved in water.*
of diabetes care across providers and
OR
practice settings indicates that sub-
stantial system-level improvements A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory
using a method that is NGSP certified and standardized to the Diabetes
are still needed.
Control and Complications Trial assay.*
Chronic Care Model OR
Numerous interventions to improve
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis,
adherence to the recommended a random plasma glucose ≥200 mg/dL (11.1 mmol/L).
standards have been implemented.
*In the absence of unequivocal hyperglycemia, results should be confirmed
However, a major barrier to optimal
by repeat testing.
care is a delivery system that is often
fragmented, lacks clinical information
are fundamental to the success- and change the societal determinants
capabilities, duplicates services, and is
ful implementation of the CCM. of these problems.
poorly designed for the coordinated
Collaborative, multidisciplinary
delivery of chronic care. The Chronic Recommendations
teams are best suited to provide care
Care Model (CCM) takes these fac- • Providers should assess social
for people with chronic conditions
tors into consideration and is an ef- context, including potential food
such as diabetes and to facilitate
fective framework for improving the insecurity, housing stability, and
patients’ self-management.
quality of diabetes care. financial barriers, and apply that
Strategies for System-Level information to treatment deci-
Six Core Elements
Improvement sions. A
The CCM includes six core elements
Optimal diabetes management re- • Patients should be referred to local
to optimize the care of patients with
quires an organized, systematic ap- community resources when avail-
chronic disease:
proach and the involvement of a co- able. B
1. Delivery system design (moving
ordinated team of dedicated health • Patients should be provided with
from a reactive to a proactive care
care professionals working in an en- self-management support from
delivery system where planned
vironment where patient-centered, lay health coaches, navigators, or
visits are coordinated through a
high-quality care is a priority. Three community health workers when
team-based approach)
objectives to achieve this include: available. A
2. Self-management support
3. Decision support (basing care • Optimizing provider and team CLASSIFICATION AND
on evidence-based, effective care behavior
DIAGNOSIS OF DIABETES
guidelines) • Supporting patient self-manage-
Diabetes can be classified into the fol-
4. Clinical information systems ment
lowing general categories:
(using registries that can provide • Changing the care system
1. Type 1 diabetes (due to auto-
patient-specific and popula-
Tailoring Treatment to Reduce immune β-cell destruction,
tion-based support to the care
Disparities usually leading to absolute insu-
team)
Social determinants of health can be lin deficiency)
5. Community resources and pol-
defined as the economic, environmen- 2. Type 2 diabetes (due to a pro-
icies (identifying or developing
tal, political, and social conditions in gressive loss of β-cell insulin
resources to support healthy
which people live and are responsible secretion frequently on the back-
lifestyles)
for a major part of health inequality ground of insulin resistance)
6. Health systems (to create a qual-
worldwide. Given the tremendous 3. Gestational diabetes mellitus
ity-oriented culture)
burden that obesity, unhealthy eat- (GDM) (diabetes diagnosed in
Redefining the roles of the health ing, physical inactivity, and smoking the second or third trimester
care delivery team and empow- place on the health of patients with of pregnancy that is not clearly
ering patient self-management diabetes, efforts are needed to address overt diabetes prior to gestation)
2 CLINICAL.DIABETESJOURNALS.ORG
abridged standards of care
Clinical Diabetes Papers In Press, published online December 15, 2016
The American Diabetes Association
TABLE 2. Criteria for Testing for Diabetes or Prediabetes in
Risk Test is an additional option for
Asymptomatic Adults
screening.
1. Testing should be considered in overweight or obese (BMI ≥25 kg/m2
or ≥23 kg/m2 in Asian Americans) adults who have one or more of the COMPREHENSIVE
following risk factors: MEDICAL EVALUATION
• A1C ≥5.7% (39 mmol/mol), impaired glucose tolerance, or impaired AND ASSESSMENT OF
fasting glucose on previous testing COMORBIDITIES
• First-degree relative with diabetes The comprehensive medical evalua-
• High-risk race/ethnicity (e.g., African American, Latino, Native tion includes the initial and ongoing
American, Asian American, Pacific Islander) evaluations, assessment of complica-
tions, management of comorbid con-
• Women who were diagnosed with GDM
ditions, and engagement of the pa-
• History of CVD
tient throughout the process. People
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
with diabetes should receive health
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglycer- care from a team that may include
ide level >250 mg/dL (2.82 mmol/L)
physicians, nurse practitioners, physi-
• Women with polycystic ovary syndrome cian assistants, nurses, dietitians, exer-
• Physical inactivity cise specialists, pharmacists, dentists,
podiatrists, and mental health pro-
• Other clinical conditions associated with insulin resistance (e.g.,
severe obesity, acanthosis nigricans) fessionals. Individuals with diabetes
must assume an active role in their
2. For all patients, testing should begin at age 45 years.
care. The patient, family, physician,
3. If results are normal, testing should be repeated at a minimum of 3-year
and health care team should formu-
intervals, with consideration of more frequent testing depending on
late the management plan, which in-
initial results (e.g., those with prediabetes should be tested yearly) and
risk status. cludes lifestyle management.
Lifestyle management and psy-
TABLE 3. Referrals for Initial Care Management chosocial care are the cornerstones of
• Eye care professional for annual dilated eye exam diabetes management. Patients should
be referred for diabetes self-manage-
• Family planning for women of reproductive age
ment education (DSME), diabetes
• Registered dietitian for MNT
self-management support (DSMS),
• DSME and DSMS medical nutrition therapy (MNT),
• Dentist for comprehensive dental and periodontal examination and psychosocial/emotional health
concerns if indicated. Additional
• Mental health professional, if indicated
referrals should be arranged as neces-
4. Other specific types, including Type 2 Diabetes and sary (Table 3). Patients should receive
monogenic forms of diabetes Prediabetes recommended preventive care ser-
vices (e.g., immunizations and cancer
Diagnostic Tests for Diabetes Recommendations screening); smoking cessation coun-
Diabetes may be diagnosed based on • Screening to assess prediabetes seling; and ophthalmological, dental,
and risk for future diabetes with
plasma glucose criteria—either the and podiatric referrals. Clinicians
an informal assessment of risk
fasting plasma glucose (FPG) or the should ensure that individuals with
factors or validated tools should
2-h plasma glucose value after a 75-g diabetes are appropriately screened
oral glucose tolerance test (OGTT) be considered in asymptomatic for complications and comorbidities.
adults. B
— or A1C (Table 1). Comprehensive Medical
• To test for prediabetes, FPG,
The same tests are used to screen Evaluation
OGTT, and A1C are equally
for and diagnose diabetes and to The components of the comprehen-
appropriate. B
detect individuals with prediabetes sive diabetes medical evaluation are
• Testing for prediabetes and type 2
(Table 2). Prediabetes is defined as listed in Table 4.
diabetes should be considered in
FPG of 100–125 mg/dL (5.6–6.9 children and adolescents who are Recommendations
mmol/L); 2-hr OGTT of 140–199 overweight or obese and who have A complete medical evaluation should
mg/dL (7.8–11.0 mmol/L); or A1C two or more additional risk factors be performed at the initial visit to
of 5.7–6.4% (39–47 mmol/mol). for diabetes. E • Confirm the diagnosis and classify
CLINICAL DIABETES 3
POSITION STATEMENT
Clinical Diabetes Papers In Press, published online December 15, 2016
TABLE 4. Components of the Comprehensive Diabetes Medical Evaluation*
Medical history
• Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis [DKA], asymptomatic laboratory finding)
• Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and physical activity
habits; nutrition education and behavioral support history and needs
• Complementary and alternative medicine use
• Presence of common comorbidities and dental disease
• Screen for depression, anxiety, and disordered eating using validated and appropriate measures**
• Screen for diabetes distress using validated and appropriate measures**
• Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial,
logistical, and support resources
• History of tobacco use, alcohol consumption, and substance use
• DSME and DSMS history and needs
• Review of previous treatment regimens and response to therapy (A1C records)
• Assess medication-taking behaviors and barriers to medication adherence
• Results of glucose monitoring and patient’s use of data
• DKA frequency, severity, and cause
• Hypoglycemia episodes, awareness, frequency, and causes
• History of increased blood pressure and abnormal lipids
• Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot
lesions; autonomic, including sexual dysfunction and gastroparesis)
• Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease
• For women with child-bearing capacity, review contraception and preconception planning
Physical examination
• Height, weight, and BMI; growth and pubertal development in children and adolescents
• Blood pressure determination, including orthostatic measurements when indicated
• Fundoscopic examination
• Thyroid palpation
• Skin examination (e.g., for acanthosis nigricans and insulin injection or infusion set insertion sites)
• Comprehensive foot examination:
❍ Inspection
❍ Palpation of dorsalis pedis and posterior tibial pulses
❍ Presence/absence of patellar and Achilles reflexes
❍ Determination of proprioception, vibration, and monofilament sensation
Laboratory evaluation
• A1C, if results not available within the past 3 months
• If not performed/available within the past year:
❍ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed
❍ Liver function tests
❍ Spot urinary albumin–to–creatinine ratio
❍ Serum creatinine and eGFR
❍ Thyroid-stimulating hormone in patients with type 1 diabetes
*The comprehensive medical evaluation should all ideally be done on the initial visit, but if time is limited different
components can be done as appropriate on follow-up visits
**Refer to the ADA position statement “Psychochsocial Care for People With Diabetes” for additional details on
diabetes-specific screening measures.
4 CLINICAL.DIABETESJOURNALS.ORG
abridged standards of care
Clinical Diabetes Papers In Press, published online December 15, 2016
diabetes. B thyroid disease and celiac disease (relative risk 1.7) diabetes in both
• Detect diabetes complications and soon after diagnosis. E sexes. Type 1 diabetes is associated
potential comorbid conditions. E with osteoporosis, but in type 2 dia-
Cancer
• Review previous treatment and betes, an increased risk of hip fracture
Diabetes is associated with increased
risk factor control in patients with is seen despite higher bone mineral
risk of cancers of the liver, pancreas,
established diabetes. E density.
endometrium, colon/rectum, breast,
• Begin patient engagement in the
and bladder. The association may re- Hearing Impairment
formulation of a care management
sult from shared risk factors between Hearing impairment, both in high-
plan. B
diabetes and cancer (older age, obesi- frequency and low- to mid-frequen-
• Develop a plan for continuing
ty, and physical inactivity) or diabe- cy ranges, is more common in peo-
care. B
tes-related factors such as underlying ple with diabetes than in those with-
Immunization disease physiology or diabetes treat- out, perhaps due to neuropathy and/
ments, although evidence for these or vascular disease.
Recommendations
links is scarce. Patients with diabetes
• Provide routine vaccinations for Low Testosterone in Men
should be encouraged to undergo rec-
children and adults with diabetes Mean levels of testosterone are lower
ommended age- and sex-appropriate
according to age-related recom- in men with diabetes compared with
cancer screenings and to reduce their
mendations. C age-matched men without diabetes,
modifiable cancer risk factors (obesity,
• Annual vaccination against influ- but obesity is a major confounder.
physical inactivity, and smoking).
enza is recommended for all Treatment in asymptomatic men is
people with diabetes ≥6 months Cognitive Impairment/ controversial. The evidence that tes-
of age. C Dementia tosterone replacement affects out-
• Vaccination against pneumonia is Diabetes is associated with a signifi- comes is mixed, and recent guidelines
recommended for all people with cantly increased risk and rate of cog- do not recommend testing or treating
diabetes who are 2–64 years of age nitive decline and an increased risk men without symptoms.
with pneumococcal polysaccha- of dementia. In a 15-year prospective
Obstructive Sleep Apnea
ride vaccine (PPSV23). At age ≥65 study of community-dwelling peo-
ple >60 years of age, the presence Age-adjusted rates of obstructive sleep
years, administer the pneumococ-
of diabetes at baseline significantly apnea, a risk factor for cardiovascu-
cal conjugate vaccine (PCV13) at
increased the age- and sex-adjust- lar disease (CVD), are significantly
least 1 year after vaccination with
ed incidence of all-cause dementia, higher (4- to 10-fold) with obesity,
PPSV23, followed by another dose
Alzheimer’s disease, and vascular de- and especially with central obesity.
of vaccine PPSV23 at least 1 year
mentia compared with rates in those The prevalence of obstructive sleep
after PCV13 and at least 5 years
with normal glucose tolerance. apnea in the population with type 2
after the last dose of PPSV23. C
diabetes may be as high as 23%, and
• Administer three-dose series of Fatty Liver Disease
the prevalence of any sleep disordered
hepatitis B vaccine to unvacci- Elevations of hepatic transaminase
breathing may be as high as 58%.
nated adults with diabetes who concentrations are associated with
are aged 19–59 years. C higher BMI, waist circumference, Periodontal Disease
• Consider administering three- and triglyceride levels and lower Periodontal disease is more severe
dose series of hepatitis B vaccine to HDL cholesterol levels. In a prospec- and may be more prevalent in people
unvaccinated adults with diabetes tive analysis, diabetes was significantly with diabetes than in those without.
who are ≥60 years of age. C associated with incident nonalcoholic Current evidence suggests that peri-
chronic liver disease and with hepato- odontal disease adversely affects di-
Comorbidities
cellular carcinoma. Interventions that abetes outcomes, although evidence
Besides assessing diabetes-related
improve metabolic abnormalities in for treatment benefits on diabetes
complications, clinicians and their
patients with diabetes (weight loss, control remains unclear.
patients need to be aware of com-
glycemic control, and treatment with
mon comorbidities that affect people Psychosocial Disorders
specific drugs for hyperglycemia or
with diabetes and may complicate Prevalence of clinically significant
dyslipidemia) are also beneficial for
management. psychopathology in people with di-
fatty liver disease.
abetes ranges across diagnostic cate-
Autoimmune Diseases
Fractures gories, and some diagnoses are con-
Recommendations Age-specific hip fracture risk is signifi- siderably more common in people
• Consider screening patients with cantly increased in people with both with diabetes than for those without
type 1 diabetes for autoimmune type 1 (relative risk 6.3) and type 2 the disease. Symptoms, both clinical
CLINICAL DIABETES 5
POSITION STATEMENT
Clinical Diabetes Papers In Press, published online December 15, 2016
and subclinical, that interfere with a in conjunction with collaborative self-management, both at diagno-
person’s ability to carry out diabetes care with the patient’s diabetes sis and as needed thereafter. B
self-management must be addressed. treatment team. A • Effective self-management and
Diabetes distress is very common and improved clinical outcomes,
Disordered Eating Behavior
distinct from a psychological disorder. health status, and quality of
Anxiety Disorders Recommendations life are key goals of DSME and
• Providers should consider reeval- DSMS that should be measured
Recommendations uating the treatment regimen of and monitored as part of routine
• Consider screening for anxiety people with diabetes who present care. C
in people exhibiting anxiety or with symptoms of disordered eat- • DSME and DSMS should be
worries regarding diabetes com-
ing behavior, an eating disorder, patient-centered, respectful, and
plications, insulin injections or
or disrupted patterns of eating. B responsive to individual patient
infusion, taking medications,
• Consider screening for disor- preferences, needs, and values,
and/or hypoglycemia that interfere
dered or disrupted eating using and should help guide clinical
with self-management behaviors
validated screening measures decisions. A
and those who express fear, dread,
when hyperglycemia and weight • DSME and DSMS programs
or irrational thoughts and/or show
loss are unexplained based on have the necessary elements in
anxiety symptoms such as avoid-
self-reported behaviors related to
ance behaviors, excessive repetitive their curricula to delay or prevent
medication dosing, meal plan,
behaviors, or social withdrawal. the development of type 2 diabe-
and physical activity. In addition,
Refer for treatment if anxiety is tes. DSME and DSMS programs
a review of the medical regimen is
present. B should therefore be able to tailor
recommended to identify poten-
• People with hypoglycemic their content when prevention of
tial treatment-related effects on
unawareness, which can co-occur diabetes is the desired goal. B
hunger/caloric intake. B
with fear of hypoglycemia, should • Because DSME and DSMS can
be treated using Blood Glucose Serious Mental Illness improve outcomes and reduce
Awareness Training (or another costs B, DSME and DSMS
Recommendations
similar evidence-based interven- should be adequately reimbursed
tion) to help re-establish awareness • Annually screen people who are by third-party payers. E
of hypoglycemia and reduce fear prescribed atypical antipsychotic
of hyperglycemia. A medications for prediabetes or The overall objectives of DSME
diabetes. B and DSMS are to support informed
Depression
• Incorporate monitoring of diabetes decision-making, self-care behaviors,
Recommendations self-care activities into treatment problem-solving, and active collabo-
• Providers should consider annual goals in people with diabetes and ration with the health care team to
screening of all patients with serious mental illness. B improve clinical outcomes, health
diabetes, especially those with a
LIFESTYLE MANAGEMENT status, and quality of life in a cost-
self-reported history of depres-
effective manner.
Lifestyle management is a fundamen-
sion, for depressive symptoms
tal aspect of diabetes care, and in- Four critical time points have
with age-appropriate depression
cludes DSME and DSMS, nutrition, been defined when the need for
screening measures, recognizing
physical activity, smoking cessation, DSME and DSMS should be eval-
that further evaluation will be
and psychosocial care. uated by the medical care provider
necessary for individuals who have
and/or multidisciplinary team, with
a positive screen. B DSME and DSMS
referrals made as needed:
• Beginning at diagnosis of com-
Recommendations 1. At diagnosis
plications or when there are
significant changes in medical • In accordance with the national 2. Annually for assessment of edu-
status, consider assessment for standards for DSME and DSMS, cation, nutrition, and emotional
depression. B all people with diabetes should needs
• Referrals for treatment of depres- participate in DSME to facilitate 3. When new complicating factors
sion should be made to mental the knowledge, skills, and ability (health conditions, physical lim-
health providers with experience necessary for diabetes self-care itations, emotional factors, or
using cognitive behavioral therapy, and in DSMS to assist with imple- basic living needs) arise that influ-
interpersonal therapy, or other evi- menting and sustaining skills and ence self-management
dence-based treatment approaches behaviors needed for ongoing 4. When transitions in care occur
6 CLINICAL.DIABETESJOURNALS.ORG
abridged standards of care
Clinical Diabetes Papers In Press, published online December 15, 2016
TABLE 5. MNT Recommendations
Topic Recommendations Evidence Rating
Effectiveness of • An individualized MNT program, preferably provided by a registered A
nutrition therapy dietitian, is recommended for all people with type 1 or type 2 diabetes.
• For people with type 1 diabetes and those with type 2 diabetes who are A
prescribed a flexible insulin therapy program, education on how to use
carbohydrate counting and, in some cases, fat and protein gram
estimation to determine mealtime insulin dosing can improve glycemic
control.
• For individuals whose daily insulin dosing is fixed, having a consistent B
pattern of carbohydrate intake with respect to time and amount can
result in improved glycemic control and a reduced risk of hypoglycemia.
• A simple and effective approach to glycemia and weight management B
emphasizing portion control and healthy food choices may be more
helpful for those with type 2 diabetes who are not taking insulin, who
have limited health literacy or numeracy, or who are elderly and prone to
hypoglycemia.
• Because diabetes nutrition therapy can result in cost savings B and B, A, E
improved outcomes (e.g., A1C reduction) A, MNT should be adequately
reimbursed by insurance and other payers. E
Energy balance • Modest weight loss achievable by the combination of reduction of A
caloric intake and lifestyle modification benefits overweight or
obese adults with type 2 diabetes and also those with prediabetes.
Intervention programs to facilitate this process are recommended.
Eating patterns • Because there is no single ideal dietary distribution of calories among E
and macronutrient carbohydrates, fats, and proteins for people with diabetes, macronutri-
distribution ent distribution should be individualized while keeping total caloric and
metabolic goals in mind.
• A variety of eating patterns are acceptable for the management of type B
2 diabetes and prediabetes including the Mediterranean diet, DASH,
and plant-based diets.
• Carbohydrate intake from whole grains, vegetables, fruits, legumes, and B
dairy products, with an emphasis on foods higher in fiber and lower in
glycemic load, should be advised over other sources, especially those
containing sugars.
• People with diabetes and those at risk should avoid sugar-sweetened B, A
beverages to control weight and reduce their risk for CVD and fatty liver
disease B and should minimize their consumption of foods with added
sugar that have the capacity to displace healthier, more nutrient-dense
food choices. A
Protein • In individuals with type 2 diabetes, ingested protein appears to increase B
insulin response without increasing plasma glucose concentrations.
Therefore, carbohydrate sources high in protein should not be used to
treat or prevent hypoglycemia.
Dietary fat • Whereas data on the ideal total dietary fat content for people with B
diabetes are inconclusive, an eating plan emphasizing elements of a
Mediterranean-style diet rich in monounsaturated fats may improve
glucose metabolism and lower CVD risk and can be an effective
alternative to a diet low in total fat but relatively high in carbohydrates.
• Eating foods rich in long-chain Ω-3 fatty acids, such as fatty fish (EPA B, A
and DHA) and nuts and seeds (ALA) is recommended to prevent or treat
CVD B; however, evidence does not support a beneficial role for Ω-3
dietary supplements. A
TABLE CONTINUED ON P. 8 →
CLINICAL DIABETES 7
POSITION STATEMENT
Clinical Diabetes Papers In Press, published online December 15, 2016
TABLE 5. MTNATB LREe c5o. mMmNeTn Rdeactoiomnms, ecnodnatitniounesd from p. 7
Topic Recommendations Evidence Rating
Micronutrients • There is no clear evidence that dietary supplementation with vitamins, C
and herbal minerals, herbs, or spices can improve outcomes in people with
supplements diabetes who do not have underlying deficiencies, and there may
be safety concerns regarding the long-term use of antioxidant
supplements such as vitamins E and C and carotene.
Alcohol • Adults with diabetes who drink alcohol should do so in moderation C
(no more than one drink per day for adult women and no more than
two drinks per day for adult men).
• Alcohol consumption may place people with diabetes at increased B
risk for hypoglycemia, especially if they are taking insulin or insulin
secretagogues. Education and awareness regarding the recognition
and management of delayed hypoglycemia are warranted.
Sodium • As for the general population, people with diabetes should limit sodium B
consumption to <2,300 mg/day, although further restriction may be
indicated for those with both diabetes and hypertension.
Non-nutritive • The use of nonnutritive sweeteners has the potential to reduce overall B
Sweeteners caloric and carbohydrate intake if substituted for caloric sweeteners and
without compensation by intake of additional calories from other food
sources. Nonnutritive sweeteners are generally safe to use within the
defined acceptable daily intake levels.
Nutrition Therapy abetes should engage in 60 min/ diabetes. Yoga and tai chi may
For many individuals with diabe- day or more of moderate or vigor- be included based on individual
tes, the most challenging part of the ous intensity aerobic activity, with preferences to increase flexibility,
treatment plan is determining what vigorous, muscle-strengthening, muscular strength, and balance. C
to eat and following a food plan. and bone-strengthening activities
Exercise in the Presence
There is not a one-size-fits-all eating included at least 3 days/week. C
pattern for individuals with diabe- • Most adults with with type 1 C or of Specific Long-Term
tes. The Mediterranean diet, Dietary type 2 B diabetes should engage Complications of Diabetes
Approaches to Stop Hypertension in 150 min or more of moder-
Retinopathy
(DASH) diet, and plant-based diets ate-to-vigorous intensity activity
If proliferative diabetic retinopathy or
are all examples of healthful eating per week, spread over at least 3
severe nonproliferative diabetic reti-
patterns. See Table 5 for specific nu- days/week, with no more than 2
nopathy is present, then vigorous-in-
trition recommendations. consecutive days without activity.
tensity aerobic or resistance exercise
In overweight and obese patients Shorter durations (minimum 75
may be contraindicated because of the
with type 2 diabetes, modest weight min/week) of vigorous-intensity or
risk of triggering vitreous hemorrhage
loss, defined as sustained reduc- interval training may be sufficient
or retinal detachment. Consultation
tion of 5% of initial body weight, for younger and more physically
has been shown to improve glyce- fit individuals. with an ophthalmologist prior to en-
mic control and to reduce the need • Adults with type 1 C or type 2 gaging in an intense exercise regimen
for glucose-lowering medications. B diabetes should engage in 2−3 may be appropriate.
However, sustaining weight loss can sessions/week of resistance exercise
Peripheral Neuropathy
be challenging. Weight loss can be on nonconsecutive days.
Decreased pain sensation and a high-
attained with lifestyle programs that • All adults, and particularly those
er pain threshold in the extremities
achieve a 500–750 kcal/day energy with type 2 diabetes, should
result in an increased risk of skin
deficit or provide ~1,200–1,500 kcal/ decrease the amount of time spent
breakdown, infection, and Charcot
day for women and 1,500–1,800 in daily sedentary behavior. B
joint destruction with some forms of
kcal/day for men, adjusted for the Prolonged sitting should be inter-
exercise. Therefore, a thorough assess-
individual's baseline body weight. rupted every 30 min for blood
glucose benefits, particularly in ment should be done to ensure that
Physical Activity
adults with type 2 diabetes. C neuropathy does not alter kinesthetic
Recommendations • Flexibility training and balance or proprioceptive sensation during
• Children and adolescents with training are recommended 2−3 physical activity, particularly in those
type 1 or type 2 diabetes or predi- times/week for older adults with with more severe neuropathy.
8 CLINICAL.DIABETESJOURNALS.ORG
abridged standards of care
Clinical Diabetes Papers In Press, published online December 15, 2016
Smoking Cessation: Tobacco • Patients with prediabetes should Recommendation
and e-Cigarettes be referred to an intensive • Most patients using intensive
behavioral lifestyle intervention insulin regimens (multiple-dose
Recommendations
program modelled on the Diabetes insulin or insulin pump therapy)
• Advise all patients not to use ciga-
Prevention Program to achieve should perform SMBG prior to
rettes and other tobacco products
and maintain 7% loss of initial meals and snacks, at bedtime,
A or e-cigarettes. E
body weight and increase mod- occasionally postprandially, prior
• Include smoking cessation
to exercise, when they suspect low
counseling and other forms of erate-intensity physical activity
blood glucose, after treating low
treatment as a routine component (such as brisk walking) to at least
blood glucose until they are nor-
of diabetes care. B 150 min/week. A
moglycemic, and prior to critical
• Metformin therapy for prevention
Psychosocial Issues tasks such as driving. B
of type 2 diabetes should be con-
Recommendations sidered in those with prediabetes,
SMBG allows patients to evaluate
• Psychosocial care should be especially for those with a BMI
their individual responses to therapy
integrated with a collaborative, ≥ 35 kg/m2, those <60 years of and assess whether glycemic targets
patient-centered approach and age, and women with prior GDM, are being achieved. Results of SMBG
provided to all people with diabe- and/or those with rising A1C can be useful in preventing hypogly-
tes, with the goals of optimizing despite lifestyle intervention. A cemia and adjusting medications
health outcomes and health-re- • Screening for and treatment of (particularly prandial insulin doses),
lated quality of life. A modifiable risk factors for CVD MNT, and physical activity. Evidence
• Psychosocial screening and fol- is suggested for those with predi- also supports a correlation between
low-up may include, but are not abetes. B SMBG frequency and meeting A1C
limited to, attitudes about the
targets.
illness, expectations for medi- Intensive lifestyle modification pro- SMBG accuracy is instrument-
cal management and outcomes, grams have been shown to be very and user-dependent. Evaluate each
affect or mood, general and diabe- effective (∼58% risk reduction after patient’s monitoring technique, both
tes-related quality of life, available 3 years). In addition, pharmacologic initially and at regular intervals
resources (financial, social, and agents including metformin, α-glu- thereafter. The ongoing need for and
emotional), and psychiatric his- cosidase inhibitors, orlistat, gluca- frequency of SMBG should be reeval-
tory. E gon-like peptide 1 (GLP-1) receptor uated at each routine visit.
• Providers should consider assess-
agonists, and thiazolidinediones have
A1C Testing
ment for symptoms of diabetes
been shown to decrease incident dia-
distress, depression, anxiety, and betes to various degrees. Metformin Recommendations
disordered eating, as well as has demonstrated long-term safety as • Perform the A1C test at least two
cognitive capacities, using pharmacologic therapy for diabetes times a year in patients who are
patient-appropriate standardized prevention. meeting treatment goals (and who
and validated tools at the initial have stable glycemic control). E
visit, at periodic intervals, and GLYCEMIC TARGETS • Perform the A1C test quarterly
when there is a change in disease, Assessment of Glycemic in patients whose therapy has
treatment, or life circumstances. changed or who are not meeting
Control
Including caregivers and family glycemic goals. E
Self-monitoring of blood glucose
members in this assessment is rec- • Point-of-care testing for A1C pro-
(SMBG) frequency and timing
ommended. B vides the opportunity for more
should be dictated by patients’ spe-
• Consider screening older adults timely treatment changes. E
cific needs and goals. SMBG is es-
(aged ≥65 years) with diabetes for
pecially important for patients treat-
cognitive impairment and depres- For patients in whom A1C and
sion. B ed with insulin to monitor for and measured blood glucose appear dis-
prevent asymptomatic hypoglycemia crepant, clinicians should consider
PREVENTION OR DELAY OF
and hyperglycemia. For patients on the possibilities of hemoglobinopathy
TYPE 2 DIABETES
nonintensive insulin regimens such as or altered red blood cell turnover and
Recommendations those with type 2 diabetes using bas- the options of more frequent and/or
• At least annual monitoring for the al insulin, when to prescribe SMBG different timing of SMBG or con-
development of diabetes in those and at what testing frequency are less tinuous glucose monitoring. Other
with prediabetes is suggested. E established. measures of chronic glycemia such
CLINICAL DIABETES 9
POSITION STATEMENT
Clinical Diabetes Papers In Press, published online December 15, 2016
as fructosamine are available, but Approach to the Management of Hyperglycemia
their linkage to average glucose and
Patient / Disease Features More stringent A1C 7% Less stringent
their prognostic significance are not
as clear as for A1C. Risks potentially associated
with hypoglycemia and
other drug adverse effects
A1C Goals low high
Recommendations
U
• A reasonable A1C goal for many Disease duration newly diagnosed long-standing sua
nonpregnant adults is <7% (53 lly
n
mmol/mol). A o
• Providers might reasonably sug- Life expectancy long short t mo
d
gest more stringent A1C goals ifi
a
(such as <6.5% [48 mmol/mol]) ble
Relevant comorbidities
for selected individual patients if absent few / mild severe
this can be achieved without sig-
Established vascular
nificant hypoglycemia or other
complications
adverse effects of treatment (i.e., absent few / mild severe
polypharmacy). Appropriate Po
te
patients might include those with n
Patient attitude and highly motivated, adherent, less motivated, nonadherent, tia
a short duration of diabetes, type expected treatment efforts excellent self-care capabilities poor self-care capabilities lly
m
2 diabetes treated with lifestyle or
o
d
metformin only, long life expec- Resources and support ifi
tancy, or no significant CVD. C system readily available limited able
• Less stringent A1C goals (such ■ FIGURE 1. Depicted are patient and disease factors used to determine optimal
as <8% [64 mmol/mol]) may be
A1C targets. Characteristics and predicaments toward the left justify more stringent
appropriate for patients with a
efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted
history of severe hypoglycemia,
with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.
limited life expectancy, advanced
microvascular or macrovascular provided in Table 6. The recommen- to prevent recurrence of hypogly-
complications, extensive comor- dations include blood glucose levels cemia. E
bid conditions, or long-standing that appear to correlate with achieve- • Glucagon should be prescribed
diabetes in whom the goal is dif- ment of an A1C of ≤7% (53 mmol/ for all individuals at increased
ficult to achieve despite DSME, mol). risk of clinically significant hypo-
appropriate glucose monitoring, glycemia, defined as blood glucose
Hypoglycemia
and effective doses of multiple <54 mg/dL (3.0 mmol/L), so it is
The 2017 Standards of Care provides
glucose-lowering agents, including available should it be needed.
a new classification of hypoglycemia.
insulin. B Caregivers, school personnel, or
Recommendations family members of these individ-
The complete 2017 Standards of • Individuals at risk for hypogly- uals should know where it is and
Care includes additional goals for cemia should be asked about when and how to administer it.
children and pregnant women. symptomatic and asymptomatic The use of glucagon is indicated
Glycemic control achieved using hypoglycemia at each encounter. for the treatment of hypoglycemia
A1C targets of <7% (53 mmol/mol) C in people unable or unwilling to
has been shown to reduce micro- • Glucose (15–20 g) is the pre- consume carbohydrates by mouth.
vascular complications of diabetes, ferred treatment for conscious Glucagon administration is not
and, in type 1 diabetes, mortality. individuals with hypoglycemia limited to health care profession-
There is evidence for cardiovascular (glucose alert value of ≤70 mg/ als. E
benefit of intensive glycemic control dL), although any form of car- • Hypoglycemia unawareness or
after long-term follow-up of people bohydrate that contains glucose one or more episodes of severe
treated early in the course of type 1 may be used. Fifteen minutes after hypoglycemia should trigger
and type 2 diabetes, however optimal treatment, if SMBG shows contin- reevaluation of the treatment reg-
A1C targets should be individualized ued hypoglycemia, the treatment imen. E
based on several patient-specific and should be repeated. Once SMBG • Insulin-treated patients with
disease-specific factors (Figure 1). returns to normal, the individual hypoglycemia unawareness or an
Recommended glycemic targets are should consume a meal or snack episode of clinically significant
10 CLINICAL.DIABETESJOURNALS.ORG