Executive Summary: Standards of MedicalCare in Diabetes—2011

Current criteria for the diagnosis ofdiabetes● A1C �6.5%. The test should be per-

formed in a laboratory using a methodthat is National Glycohemoglobin Stan-dardization Program (NGSP)-certifiedand standardized to the Diabetes Con-trol and Complications Trial (DCCT)assay

● fasting plasma glucose (FPG) �126mg/dl (7.0 mmol/l). Fasting is definedas no caloric intake for at least 8 h, or

● 2-h plasma glucose �200 mg/dl (11.1mmol/l) during an oral glucose toler-ance test (OGTT). The test should beperformed as described by the WorldHealth Organization, using a glucoseload containing the equivalent of 75 ganhydrous glucose dissolved in water

● in a patient with classic symptoms ofhyperglycemia or hyperglycemic crisis,a random plasma glucose �200 mg/dl(11.1 mmol/l)

● in the absence of unequivocal hypergly-cemia, result should be confirmed byrepeat testing.

Testing for diabetes in asymptomaticpatients● Testing to detect type 2 diabetes and

assess risk for future diabetes in asymp-tomatic people should be considered inadults of any age who are overweight orobese (BMI �25 kg/m2) and who haveone or more additional risk factors fordiabetes (see Table 4 of the “Standardsof Medical Care in Diabetes—2011”).In those without these risk factors, test-ing should begin at age 45 years. (B)

● If tests are normal, repeat testing car-ried out at least at 3-year intervals isreasonable. (E)

● To test for diabetes or to assess risk offuture diabetes, A1C, FPG, or 2-h 75-gOGTT are appropriate. (B)

● In those identified with increased riskfor future diabetes, identify and, if ap-

propriate, treat other cardiovasculardisease (CVD) risk factors. (B)

Detection and diagnosis ofgestational diabetes mellitus (GDM)● Screen for undiagnosed type 2 diabetes

at the first prenatal visit in those withrisk factors, using standard diagnosticcriteria. (B)

● In pregnant women not known to havediabetes, screen for GDM at 24 –28weeks of gestation, using a 75-g 2-hOGTT and the diagnostic cut points inTable 6 of the “Standards of MedicalCare in Diabetes—2011”. (B)

● Screen women with GDM for persistentdiabetes 6–12 weeks postpartum. (E)

● Women with a history of GDM shouldhave lifelong screening for the develop-ment of diabetes or prediabetes at leastevery 3 years. (E)

Prevention/delay of type 2 diabetes● Patients with impaired glucose toler-

ance (IGT) (A), impaired fasting glu-cose (IFG) (E), or an A1C of 5.7–6.4%(E) should be referred to an effectiveongoing support program targetingweight loss of 7% of body weight andincreasing physical activity to at least150 min/week of moderate activitysuch as walking.

● Follow-up counseling appears to be im-portant for success. (B)

● Based on potential cost-savings of dia-betes prevention, such programsshould be covered by third-party pay-ors. (E)

● Metformin therapy for prevention oftype 2 diabetes may be considered inthose at highest risk for developing di-abetes, such as those with multiple riskfactors, especially if they demonstrateprogression of hyperglycemia (e.g. A1C�6%) despite lifestyle interventions.(B)

● Monitoring for the development of di-

abetes in those with prediabetes shouldbe performed every year. (E)

Glucose monitoring● Self-monitoring of blood glucose

(SMBG) should be carried out three ormore times daily for patients using mul-tiple insulin injections or insulin pumptherapy. (A)

● For patients using less-frequent insulininjections, non-insulin therapies, ormedical nutrition therapy (MNT)alone, SMBG may be useful as a guide tothe success of therapy. (E)

● To achieve postprandial glucose tar-gets, postprandial SMBG may be appro-priate. (E)

● When prescribing SMBG, ensure thatpatients receive initial instruction in,and routine follow-up evaluation of,SMBG technique and their ability to usedata to adjust therapy. (E)

● Continuous glucose monitoring (CGM)in conjunction with intensive insulinregimens can be a useful tool to lowerA1C in selected adults (age �25 years)with type 1 diabetes. (A)

● Although the evidence for A1C-lowering is less strong in children,teens, and younger adults, CGM maybe helpful in these groups. Success cor-relates with adherence to ongoing useof the device. (C)

● CGM may be a supplemental tool toSMBG in those with hypoglycemia un-awareness and/or frequent hypoglyce-mic episodes. (E)

A1C● Perform the A1C test at least two times

a year in patients who are meeting treat-ment goals (and who have stable glyce-mic control). (E)

● Perform the A1C test quarterly in pa-tients whose therapy has changed orwho are not meeting glycemic goals. (E)

● Use of point-of-care testing for A1C al-lows for timely decisions on therapychanges, when needed. (E)

Glycemic goals in adults● Lowering A1C to below or around 7%

has been shown to reduce microvascu-lar and neuropathic complications of

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DOI: 10.2337/dc11-S004© 2011 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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diabetes and, if implemented soon afterthe diagnosis of diabetes, is associatedwith long-term reduction in macrovas-cular disease. Therefore, a reasonableA1C goal for many nonpregnant adultsis �7%. (B)

● Because additional analyses from sev-eral randomized trials suggest a smallbut incremental benefit in microvascu-lar outcomes with A1C values closer tonormal, providers might reasonablysuggest more stringent A1C goals forselected individual patients, if this canbe achieved without significant hypo-glycemia or other adverse effects oftreatment. Such patients might includethose with short duration of diabetes,long life expectancy, and no significantcardiovascular disease. (B)

● Conversely, less stringent A1C goalsmay be appropriate for patients with ahistory of severe hypoglycemia, limitedlife expectancy, advanced microvascu-lar or macrovascular complications, ex-tensive comorbid conditions, and thosewith longstanding diabetes in whomthe general goal is difficult to attain de-spite diabetes self-management educa-tion, appropriate glucose monitoring,and effective doses of multiple glucose-lowering agents including insulin. (C)

Diabetes self-management education(DSME)● People with diabetes should receive

DSME according to national standardswhen their diabetes is diagnosed and asneeded thereafter. (B)

● Effective self-management and qualityof life are the key outcomes of DSMEand should be measured and moni-tored as part of care. (C)

● DSME should address psychosocial is-sues, since emotional well-being is as-sociated with posit ive diabetesoutcomes. (C)

● Because DSME can result in cost-savings and improved outcomes (B),DSME should be adequately reim-bursed by third-party payors. (E)

Medical nutrition therapy (MNT)General recommendations● Individuals who have prediabetes or di-

abetes should receive individualizedMNT as needed to achieve treatmentgoals, preferably provided by a regis-tered dietitian familiar with the compo-nents of diabetes MNT. (A)

● Because MNT can result in cost-savingsand improved outcomes (B), MNT

should be adequately covered by insur-ance and other payors. (E)

Energy balance, overweight, andobesity● In overweight and obese insulin-

resistant individuals, modest weightloss has been shown to reduce insulinresistance. Thus, weight loss is recom-mended for all overweight or obese in-dividuals who have or are at risk fordiabetes. (A)

● For weight loss, either low-carbohy-drate, low-fat calorie-restricted, orMediterranean diets may be effective inthe short term (up to 2 years). (A)

● For patients on low-carbohydrate diets,monitor lipid profiles, renal function,and protein intake (in those with ne-phropathy) and adjust hypoglycemictherapy as needed. (E)

● Physical activity and behavior modifi-cation are important components ofweight loss programs and are mosthelpful in maintenance of weight loss.(B)

Recommendations for primaryprevention of diabetes● Among individuals at high risk for de-

veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges that include moderate weightloss (7% of body weight) and regularphysical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietaryfat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A)

● Individuals at high risk for type 2 dia-betes should be encouraged to achievethe U.S. Department of Agriculture(USDA) recommendation for dietary fi-ber (14 g fiber/1,000 kcal) and foodscontaining whole grains (one-half ofgrain intake). (B)

Recommendations for managementof diabetes: macronutrients indiabetes management● The best mix of carbohydrate, protein,

and fat may be adjusted to meet themetabolic goals and individual prefer-ences of the person with diabetes. (E)

● Monitoring carbohydrate, whether bycarbohydrate counting, choices, or ex-perience-based estimation, remains akey strategy in achieving glycemic con-trol. (A)

● For individuals with diabetes, the use ofthe glycemic index and glycemic load

may provide a modest additional bene-fit for glycemic control over that ob-served when total carbohydrate isconsidered alone. (B)

● Saturated fat intake should be �7% oftotal calories. (A)

● Reducing intake of trans fat lowers LDLcholesterol and increases HDL choles-terol (A); therefore, intake of trans fatshould be minimized. (E)

Other nutrition recommendations● If adults with diabetes choose to use

alcohol, daily intake should be limitedto a moderate amount (one drink perday or less for adult women and twodrinks per day or less for adult men).(E)

● Routine supplementation with antioxi-dants, such as vitamins E and C andcarotene, is not advised because of lackof evidence of efficacy and concern re-lated to long-term safety. (A)

● Individualized meal planning shouldinclude optimization of food choices tomeet recommended daily allowance(RDA)/dietary reference intake (DRI)for all micronutrients. (E)

Physical activity● People with diabetes should be advised

to perform at least 150 min/week ofmoderate-intensity aerobic physical ac-tivity (50 –70% of maximum heartrate). (A)

● In the absence of contraindications,people with type 2 diabetes should beencouraged to perform resistance train-ing three times per week. (A)

Psychosocial assessment and care● Assessment of psychological and social

situation should be included as an on-going part of the medical managementof diabetes. (E)

● Psychosocial screening and follow-upshould include, but is not limited to,attitudes about the illness, expectationsfor medical management and out-comes, affect/mood, general and diabe-tes-related quality of life, resources(financial, social, and emotional), andpsychiatric history. (E)

● Screen for psychosocial problems suchas depression and diabetes-related dis-tress, anxiety, eating disorders, andcognitive impairment when self-management is poor. (C)

Hypoglycemia● Glucose (15–20 g) is the preferred

treatment for the conscious individual

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care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S5

with hypoglycemia, although any formof carbohydrate that contains glucosemay be used. If SMBG 15 min aftertreatment shows continued hypoglyce-mia, the treatment should be repeated.Once SMBG glucose returns to normal,the individual should consume a mealor snack to prevent recurrence of hypo-glycemia. (E)

● Glucagon should be prescribed for allindividuals at significant risk of severehypoglycemia, and caregivers or familymembers of these individuals should beinstructed in its administration. Gluca-gon administration is not limited tohealth care professionals. (E)

● Individuals with hypoglycemia un-awareness or one or more episodes ofsevere hypoglycemia should be advisedto raise their glycemic targets to strictlyavoid further hypoglycemia for at leastseveral weeks, to partially reverse hypo-glycemia unawareness and reduce therisk of future episodes. (B)

Bariatric surgery● Bariatric surgery may be considered for

adults with BMI �35 kg/m2 and type 2diabetes, especially if the diabetes or as-sociated comorbidities are difficult tocontrol with lifestyle and pharmaco-logic therapy. (B)

● Patients with type 2 diabetes who haveundergone bariatric surgery need life-long lifestyle support and medicalmonitoring. (E)

● Although small trials have shown gly-cemic benefit of bariatric surgery in pa-tients with type 2 diabetes and BMI of30–35 kg/m2, there is currently insuf-ficient evidence to generally recom-mend surgery in patients with BMI �35kg/m2 outside of a research protocol.(E)

● The long- t e rm benefit s , cos t -effectiveness, and risks of bariatric sur-gery in individuals with type 2 diabetesshould be studied in well-designedcontrolled trials with optimal medicaland lifestyle therapy as the comparator.(E)

Immunization● Annually provide an influenza vaccine

to all diabetic patients �6 months ofage. (C)

● Administer pneumococcal polysaccha-ride vaccine to all diabetic patients �2years of age. A one-time revaccination isrecommended for individuals �64years of age previously immunizedwhen they were �65 years of age if the

vaccine was administered �5 yearsago. Other indications for repeat vacci-nation include nephrotic syndrome,chronic renal disease, and other immu-nocompromised states, such as aftertransplantation. (C)

Hypertension/blood pressure controlScreening and diagnosis● Blood pressure should be measured at

every routine diabetes visit. Patientsfound to have systolic blood pressure�130 mmHg or diastolic blood pres-sure �80 mmHg should have bloodpressure confirmed on a separate day.Repeat systolic blood pressure �130mmHg or diastolic blood pressure �80mmHg confirms a diagnosis of hyper-tension. (C)

Goals● A goal systolic blood pressure �130

mmHg is appropriate for most patientswith diabetes. (C)

● Based on patient characteristics and re-sponse to therapy, higher or lower sys-tolic blood pressure targets may beappropriate. (B)

● Patients with diabetes should be treatedto a diastolic blood pressure �80mmHg. (B)

Treatment● Patients with a systolic blood pressure

of 130–139 mmHg or a diastolic bloodpressure of 80–89 mmHg may be givenlifestyle therapy alone for a maximumof 3 months and then, if targets are notachieved, be treated with the additionof pharmacological agents. (E)

● Patients with more severe hypertension(systolic blood pressure �140 or dia-stolic blood pressure �90 mmHg) atdiagnosis or follow-up should receivepharmacologic therapy in addition tolifestyle therapy. (A)

● Lifestyle therapy for hypertension con-sists of: weight loss, if overweight;DASH (Dietary Approaches to Stop Hy-pertension)-style dietary pattern, in-c lud ing reduc ing sod ium andincreasing potassium intake; modera-tion of alcohol intake; and increasedphysical activity. (B)

● Pharmacologic therapy for patientswith diabetes and hypertension shouldbe with a regimen that includes eitheran ACE inhibitor or an ARB. If one classis not tolerated, the other should besubstituted. If needed to achieve bloodpressure targets, a thiazide diureticshould be added to those with an esti-

mated glomerular filtration rate (GFR)�30 ml/min/1.73 m2 and a loop di-uretic for those with an estimated GFR�30 ml/min/1.73 m2. (C)

● Multiple drug therapy (two or moreagents at maximal doses) is generallyrequired to achieve blood pressure tar-gets. (B)

● If ACE inhibitors, ARBs, or diuretics areused, kidney function and serum potas-sium levels should be monitored. (E)

● In pregnant patients with diabetes andchronic hypertension, blood pressuretarget goals of 110–129/65–79 mmHgare suggested in the interest of long-term maternal health and minimizingimpaired fetal growth. ACE inhibitorsand ARBs are contraindicated duringpregnancy. (E)

Dyslipidemia/lipid managementScreening● In most adult patients, measure fasting

lipid profile at least annually. In adultswith low-risk lipid values (LDL choles-terol �100 mg/dl, HDL cholesterol�50 mg/dl, and triglycerides �150mg/dl), lipid assessments may be re-peated every 2 years. (E)

Treatment recommendations and goals● Lifestyle modification focusing on the

reduction of saturated fat, trans fat,and cholesterol intake; the increase ofomega-3 fatty acids, viscous fiber,and plant stanols/sterols; weight loss(if indicated); and increased physicalactivity should be recommended toimprove the lipid profile in patientswith diabetes. (A)

● Statin therapy should be added to life-style therapy, regardless of baselinelipid levels, for diabetic patients:● with overt CVD (A)● without CVD who are over the age of

40 years and have one or more otherCVD risk factors (A)

● For patients at lower risk than above(e.g. without overt CVD and under theage of 40 years), statin therapy shouldbe considered in addition to lifestyletherapy if LDL cholesterol remains�100 mg/dl or in those with multipleCVD risk factors. (E)

● In individuals without overt CVD, theprimary goal is an LDL cholesterol�100 mg/dl (2.6 mmol/l). (A)

● In individuals with overt CVD, a lowerLDL cholesterol goal of �70 mg/dl (1.8mmol/l), using a high dose of a statin, isan option. (B)

● If drug-treated patients do not reach the

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S6 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org

above targets on maximal tolerated sta-tin therapy, a reduction in LDL choles-terol of �30–40% from baseline is analternative therapeutic goal. (A)

● Triglyceride levels �150 mg/dl (1.7mmol/l) and HDL cholesterol �40mg/dl (1.0 mmol/l) in men and �50mg/dl (1.3 mmol/l) in women are desir-able. However, LDL cholesterol–targeted statin therapy remains thepreferred strategy. (C)

● If targets are not reached on maximallytolerated doses of statins, combinationtherapy using statins and other lipid-lowering agents may be considered toachieve lipid targets but has not beenevaluated in outcome studies for eitherCVD outcomes or safety. (E)

● Statin therapy is contraindicated inpregnancy. (E)

Antiplatelet agents● Consider aspirin therapy (75–162 mg/

day) as a primary prevention strategy inthose with type 1 or type 2 diabetes atincreased cardiovascular risk (10-yearrisk �10%). This includes most men�50 years of age or women �60 yearsof age who have at least one additionalmajor risk factor (family history ofCVD, hypertension, smoking, dyslipi-demia, or albuminuria). (C)

● Aspirin should not be recommendedfor CVD prevention for adults with di-abetes at low CVD risk (10-year CVDrisk �5%, such as in men �50 years ofage and women �60 years of age withno major additional CVD risk factors),since the potential adverse effects frombleeding likely offset the potential ben-efits. (C)

● In patients in these age-groups withmultiple other risk factors (e.g. 10-yearrisk 5–10%), clinical judgment is re-quired. (E)

● Use aspirin therapy (75–162 mg/day)as a secondary prevention strategy inthose with diabetes with a history ofCVD. (A)

● For patients with CVD and docu-mented aspirin allergy, clopidogrel (75mg/day) should be used. (B)

● Combination therapy with ASA (75–162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year afteran acute coronary syndrome. (B)

Smoking cessation● Advise all patients not to smoke. (A)● Include smoking cessation counseling

and other forms of treatment as a rou-tine component of diabetes care. (B)

Coronary heart disease (CHD)screening and treatmentScreening● In asymptomatic patients, routine

screening for CAD is not recom-mended, as it does not improve out-comes as long as CVD risk factors aretreated. (A)

Treatment● In patients with known CVD, ACE in-

hibitor (C) and aspirin and statin ther-apy (A) (if not contraindicated) shouldbe used to reduce the risk of cardiovas-cular events.

● In patients with a prior myocardial in-farction, �-blockers should be contin-ued for at least 2 years after the event.(B)

● Longer-term use of �-blockers in theabsence of hypertension is reasonable ifwell tolerated, but data are lacking. (E)

● Avoid thiazolidinedione (TZD) treat-ment in patients with symptomaticheart failure. (C)

● Metformin may be used in patients withstable congestive heart failure (CHF) ifrenal function is normal. It should beavoided in unstable or hospitalized pa-tients with CHF. (C)

Nephropathy screening andtreatmentGeneral recommendations● To reduce the risk or slow the progres-

sion of nephropathy, optimize glucosecontrol. (A)

● To reduce the risk or slow the progres-sion of nephropathy, optimize bloodpressure control. (A)

Screening● Perform an annual test to assess urine

albumin excretion in type 1 diabetic pa-tients with diabetes duration of �5years and in all type 2 diabetic patientsstarting at diagnosis. (E)

● Measure serum creatinine at least annu-ally in all adults with diabetes regard-less of the degree of urine albuminexcretion. The serum creatinine shouldbe used to estimate GFR and stage thelevel of chronic kidney disease (CKD),if present. (E)

Treatment● In the treatment of the nonpregnant pa-

tient with micro- or macroalbuminuria,either ACE inhibitors or ARBs shouldbe used. (A)

● While there are no adequate head-to-head comparisons of ACE inhibitors

and ARBs, there is clinical trial supportfor each of the following statements:● In patients with type 1 diabetes, with

hypertension and any degree of albu-minuria, ACE inhibitors have beenshown to delay the progression of ne-phropathy. (A)

● In patients with type 2 diabetes, hy-pertension, and microalbuminuria,both ACE inhibitors and ARBs havebeen shown to delay the progressionto macroalbuminuria. (A)

● In patients with type 2 diabetes, hy-pertension, macroalbuminuria, andrenal insufficiency (serum creatinine�1.5 mg/dl), ARBs have been shownto delay the progression of nephrop-athy. (A)

● If one class is not tolerated, the othershould be substituted. (E)

● Reduction of protein intake to 0.8–1.0g � kg body wt–1 � day–1 in individualswith diabetes and the earlier stages ofCKD and to 0.8 g � kg body wt–1 � day–1

in the later stages of CKD may improvemeasures of renal function (urine albu-min excretion rate, GFR) and is recom-mended. (B)

● When ACE inhibitors, ARBs, or diuret-ics are used, monitor serum creatinineand potassium levels for the develop-ment of acute kidney disease and hy-perkalemia. (E)

● Continued monitoring of urine albu-min excretion to assess both responseto therapy and progression of disease isrecommended. (E)

● When estimated GFR (eGFR) is �60ml.min/1.73 m2, evaluate and managepotential complications of CKD. (E)

● Consider referral to a physician experi-enced in the care of kidney diseasewhen there is uncertainty about the eti-ology of kidney disease (heavy protein-uria, active urine sediment, absence ofretinopathy, rapid decline in GFR), dif-ficult management issues, or advancedkidney disease. (B)

Retinopathy screening and treatmentGeneral recommendations● To reduce the risk or slow the progres-

sion of retinopathy, optimize glycemiccontrol. (A)

● To reduce the risk or slow the progres-sion of retinopathy, optimize bloodpressure control. (A)

Screening● Adults and children aged 10 years or

older with type 1 diabetes should havean initial dilated and comprehensive

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care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S7

eye examination by an ophthalmologistor optometrist within 5 years after theonset of diabetes. (B)

● Patients with type 2 diabetes shouldhave an initial dilated and comprehen-sive eye examination by an ophthalmol-ogist or optometrist shortly after thediagnosis of diabetes. (B)

● Subsequent examinations for type 1and type 2 diabetic patients should berepeated annually by an ophthalmolo-gist or optometrist. Less-frequent ex-ams (every 2–3 years) may beconsidered following one or more nor-mal eye exams. Examinations will berequired more frequently if retinopathyis progressing. (B)

● High-quality fundus photographs candetect most clinically significant dia-betic retinopathy. Interpretation of theimages should be performed by atrained eye care provider. While retinalphotography may serve as a screeningtool for retinopathy, it is not a substi-tute for a comprehensive eye exam,which should be performed at least ini-tially and at intervals thereafter as rec-ommended by an eye care professional.(E)

● Women with pre-existing diabetes whoare planning a pregnancy or who havebecome pregnant should have a com-prehensive eye examination and becounseled on the risk of developmentand/or progression of diabetic retinop-athy. Eye examination should occur inthe first trimester with close follow-upthroughout pregnancy and for 1 yearpostpartum. (B)

Treatment● Promptly refer patients with any level of

macular edema, severe nonproliferativediabetic retinopathy (NPDR), or anyproliferative diabetic retinopathy(PDR) to an ophthalmologist who isknowledgeable and experienced in themanagement and treatment of diabeticretinopathy. (A)

● Laser photocoagulation therapy is indi-cated to reduce the risk of vision loss inpatients with high-risk PDR, clinicallysignificant macular edema, and somecases of severe NPDR. (A)

● The presence of retinopathy is not acontraindication to aspirin therapy forcardioprotection, as this therapy doesnot increase the risk of retinal hemor-rhage. (A)

Neuropathy screening and treatment● All patients should be screened for dis-

tal symmetric polyneuropathy (DPN) atdiagnosis and at least annually thereaf-ter, using simple clinical tests. (B)

● Electrophysiological testing is rarelyneeded, except in situations where theclinical features are atypical. (E)

● Screening for signs and symptoms ofcardiovascular autonomic neuropathyshould be instituted at diagnosis of type2 diabetes and 5 years after the diagno-sis of type 1 diabetes. Special testing israrely needed and may not affect man-agement or outcomes. (E)

● Medications for the relief of specificsymptoms related to DPN and auto-nomic neuropathy are recommended,as they improve the quality of life of thepatient. (E)

Foot care● For all patients with diabetes, perform

an annual comprehensive foot exami-nation to identify risk factors predictiveof ulcers and amputations. The foot ex-amination should include inspection,assessment of foot pulses, and testingfor loss of protective sensation (10-gmonofilament plus testing any one of:vibration using 128-Hz tuning fork,pinprick sensation, ankle reflexes, orvibration perception threshold). (B)

● Provide general foot self-care educationto all patients with diabetes. (B)

● A multidisciplinary approach is recom-mended for individuals with foot ulcersand high-risk feet, especially those with ahistory of prior ulcer or amputation. (B)

● Refer patients who smoke, have loss ofprotective sensation and structural ab-normalities, or have history of priorlower-extremity complications to footcare specialists for ongoing preventivecare and life-long surveillance. (C)

● Initial screening for peripheral arterialdisease (PAD) should include a historyfor claudication and an assessment ofthe pedal pulses. Consider obtaining anankle-brachial index (ABI), as many pa-tients with PAD are asymptomatic. (C)

● Refer patients with significant claudica-tion or a positive ABI for further vascu-lar assessment and consider exercise,medications, and surgical options. (C)

Children and adolescents

Glycemic control● Consider age when setting glycemic

goals in children and adolescents withtype 1 diabetes. (E)

Screening and management ofchronic complications in childrenand adolescents with type 1 diabetes

Nephropathy● Annual screening for microalbumin-

uria, with a random spot urine samplefor albumin-to-creatinine ratio (ACR),should be considered once the child is10 years of age and has had diabetes for5 years. (E)

● Confirmed, persistently elevated ACRon two additional urine specimensfrom different days should be treatedwith an ACE inhibitor, titrated to nor-malization of albumin excretion if pos-sible. (E)

Hypertension● Treatment of high-normal blood pres-

sure (systolic or diastolic blood pres-sure consistently above the 90thpercentile for age, sex, and height)should include dietary interventionand exercise, aimed at weight controland increased physical activity, if ap-propriate. If target blood pressure is notreached with 3–6 months of lifestyleintervention, pharmacologic treatmentshould be considered. (E)

● Pharmacologic treatment of hyperten-sion (systolic or diastolic blood pres-sure consistently above the 95thpercentile for age, sex, and height orconsistently �130/80 mmHg, if 95%exceeds that value) should be initiatedas soon as the diagnosis is confirmed.(E)

● ACE inhibitors should be consideredfor the initial treatment of hyperten-sion, following appropriate reproduc-tive counseling due to its potentialteratogenic effects. (E)

● The goal of treatment is a blood pres-sure consistently �130/80 or below the90th percentile for age, sex, and height,whichever is lower. (E)

DyslipidemiaScreening● If there is a family history of hypercho-

lesterolemia (total cholesterol �240mg/dl) or a cardiovascular event beforeage 55 years, or if family history is un-known, then a fasting lipid profileshould be performed on children �2years of age soon after diagnosis (afterglucose control has been established).If family history is not of concern, thenthe first lipid screening should be con-sidered at puberty (�10 years). All chil-dren diagnosed with diabetes at or after

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puberty should have a fasting lipid pro-file performed soon after diagnosis (af-t e r g lucose cont ro l has beenestablished). (E)

● For both age-groups, if lipids are abnor-mal, annual monitoring is recom-mended. If LDL cholesterol values arewithin the accepted risk levels (�100mg/dl [2.6 mmol/l]), a lipid profileshould be repeated every 5 years. (E)

Treatment● Initial therapy should consist of optimi-

zation of glucose control and MNT us-ing a Step 2 Amer ican Hear tAssociation diet aimed at a decrease inthe amount of saturated fat in the diet.(E)

● After the age of 10 years, the addition ofa statin in patients who, after MNT andlifestyle changes, have LDL cholesterol�160 mg/dl (4.1 mmol/l), or LDL cho-lesterol �130 mg/dl (3.4 mmol/l) andone or more CVD risk factors, is reason-able. (E)

● The goal of therapy is an LDL choles-terol value �100 mg/dl (2.6 mmol/l).(E)

Retinopathy● The first ophthalmologic examination

should be obtained once the child is�10 years of age and has had diabetesfor 3–5 years. (E)

● After the initial examination, annualroutine follow-up is generally recom-mended. Less frequent examinationsmay be acceptable on the advice of aneye care professional. (E)

Celiac disease● Children with type 1 diabetes should be

screened for celiac disease by measur-ing tissue transglutaminase or anti-endomys i a l an t ibod i e s , w i thdocumentation of normal total serumIgA levels, soon after the diagnosis ofdiabetes. (E)

● Testing should be repeated in childrenwith growth failure, failure to gainweight, weight loss, diarrhea, flatu-lence, abdominal pain, or signs of mal-absorption or in children with frequentunexplained hypoglycemia or deterio-ration in glycemic control. (E)

● Children with positive antibodiesshould be referred to a gastroenterolo-gist for evaluation with endoscopy andbiopsy. (E)

● Children with biopsy-confirmed celiacdisease should be placed on a gluten-free diet and have consultation with a

dietitian experienced in managing bothdiabetes and celiac disease. (E)

Hypothyroidism● Children with type 1 diabetes should be

screened for thyroid peroxidase andthyroglobulin antibodies at diagnosis.(E)

● TSH concentrations should be mea-sured after metabolic control has beenestablished. If normal, they should berechecked every 1–2 years, or if the pa-tient develops symptoms of thyroiddysfunction, thyromegaly, or an abnor-mal growth rate. (E)

Preconception care● A1C levels should be as close to normal

as possible (�7%) in an individual pa-tient before conception is attempted.(B)

● Starting at puberty, preconceptioncounseling should be incorporated inthe routine diabetes clinic visit for allwomen of child-bearing potential. (C)

● Women with diabetes who are contem-plating pregnancy should be evaluatedand, if indicated, treated for diabeticretinopathy, nephropathy, neuropathy,and CVD. (E)

● Medications used by such womenshould be evaluated prior to concep-tion, since drugs commonly used totreat diabetes and its complicationsmay be contraindicated or not recom-mended in pregnancy, including st-atins, ACE inhibitors, ARBs, and mostnon-insulin therapies. (E)

● Since many pregnancies are un-planned, consider the potential risksand benefits of medications that arecontraindicated in pregnancy in allwomen of child-bearing potential, andcounsel women using such medica-tions accordingly. (E)

Older adults● Older adults who are functional, cogni-

tively intact, and have significant lifeexpectancy should receive diabetes careusing goals developed for youngeradults. (E)

● Glycemic goals for older adults notmeeting the above criteria may be re-laxed using individual criteria, but hy-perglycemia leading to symptoms orrisk of acute hyperglycemic complica-tions should be avoided in all patients.(E)

● Other cardiovascular risk factorsshould be treated in older adults withconsideration of the time frame of ben-

efit and the individual patient. Treat-ment of hypertension is indicated invirtually all older adults, and lipid andaspirin therapy may benefit those withlife expectancy at least equal to the timeframe of primary or secondary preven-tion trials. (E)

● Screening for diabetes complicationsshould be individualized in olderadults, but particular attention shouldbe paid to complications that wouldlead to functional impairment. (E)

Diabetes care in the hospital● All patients with diabetes admitted to

the hospital should have their diabetesclearly identified in the medical record.(E)

● All patients with diabetes should havean order for blood glucose monitoring,with results available to all members ofthe health care team. (E)

● Goals for blood glucose levels:● Critically ill patients: Insulin therapy

should be initiated for treatment ofpersistent hyperglycemia starting at athreshold of no greater than 180mg/dl (10 mmol/l). Once insulintherapy is started, a glucose range of140–180 mg/dl (7.8 to 10 mmol/l) isrecommended for the majority ofcritically ill patients. (A)

● More stringent goals, such as 110–140 mg/dl (6.1–7.8 mmol/l) may beappropriate for selected patients, aslong as this can be achieved withoutsignificant hypoglycemia. (C)

● Critically ill patients require an intra-venous insulin protocol that hasdemonstrated efficacy and safety inachieving the desired glucose rangewithout increasing risk for severe hy-poglycemia. (E)

● Non–critically ill patients: There isno clear evidence for specific bloodglucose goals. If treated with insulin,the pre-meal blood glucose targetshould generally be �140 mg/dl (7.8mmol/l) with random blood glucose�180 mg/dl (10.0 mmol/l), providedthese targets can be safely achieved.More stringent targets may be appro-priate in stable patients with previoustight glycemic control. Less stringenttargets may be appropriate in thosewith severe comorbidites. (E)

● Scheduled subcutaneous insulin withbasal, nutritional, and correction com-ponents is the preferred method forachieving and maintaining glucosecontrol in non–critically ill patients.(C) Using correction dose or “supple-

Executive Summary

care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S9

mental” insulin to correct pre-meal hy-perglycemia in addition to scheduledprandial and basal insulin is recom-mended. (E)

● Glucose monitoring should be initi-ated in any patient not known to bediabetic who receives therapy associ-ated with high risk for hyperglycemia,including high-dose glucocorticoidtherapy, initiation of enteral or paren-teral nutrition, or other medicationssuch as octreotide or immunosup-

pressive medications. (B) If hypergly-cemia is documented and persistent,treatment is necessary. Such patientsshould be treated to the same glyce-mic goals as patients with known di-abetes. (E)

● A hypoglycemia management protocolshould be adopted and implementedby each hospital or hospital system. Aplan for treating hypoglycemia shouldbe established for each patient. Epi-sodes of hypoglycemia in the hospital

should be documented in the medialrecord and tracked. (E)

● All patients with diabetes admitted tothe hospital should have an A1C ob-tained if the result of testing in theprevious 2–3 months is not available.(E)

● Patients with hyperglycemia in the hos-pital who do not have a diagnosis ofdiabetes should have appropriate plansfor follow-up testing and care docu-mented at discharge. (E)

Executive Summary

S10 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org