Executive Summary: Standards of MedicalCare in Diabetes—2008

These standards of care are intendedto provide clinicians, patients, re-searchers, payors, and other inter-

ested individuals with the components ofdiabetes care, treatment goals, and toolsto evaluate the quality of care. While in-dividual preferences, comorbidities, andother patient factors may require modifi-cation of goals, targets that are desirablefor most patients with diabetes are pro-vided. These standards are not intendedto preclude more extensive evaluationand management of the patient by otherspecialists as needed.

The recommendations included arescreening, diagnostic, and therapeutic ac-tions that are known or believed to favor-ably affect health outcomes of patientswith diabetes. A grading system devel-oped by the American Diabetes Associa-tion and modeled after existing methodswas utilized to clarify and codify the evi-dence that forms the basis for the recom-mendations. The level of evidence thatsupports each recommendation is listedafter each recommendation using the let-ters A, B, C, or E.

For more detailed information, referto the full document: “Standards of Med-ical Care in Diabetes—2008.”

TOPIC AREAS ANDRECOMMENDATIONS

Diagnosis of Diabetes● The fasting plasma glucose (FPG) text is

the preferred test to diagnose diabetesin children and nonpregnant adults. (E)

● Use of the A1C for the diagnosis of di-abetes is not recommended at this time.(E)

Testing for Pre-diabetes andDiabetes● Testing to detect pre-diabetes and type

2 diabetes in asymptomatic peopleshould be considered in adults who areoverweight or obese (BMI �25 kg/m2)and who have one more more addi-tional risk factors for diabetes. In thosewithout these risk factors, testingshould begin at age 45. (B)

● If tests are normal, repeat testing shouldbe carried out at least at 3-year inter-vals. (E)

● To test for pre-diabetes or diabetes, ei-ther an FPG test or 2-h oral glucose tol-erance test (OGTT; 75-g glucose load),or both, is appropriate. (B)

● An OGTT may be considered in pa-tients with impaired fasting glucose(IFG) to better define the risk of diabe-tes. (E)

● In those identified with pre-diabetes,identify and, if appropriate, treat otherCVD risk factors. (B)

Testing for Type 2 Diabetes inChildren● Test children who are overweight (BMI

�85th percentile for age and sex,weight for height �85th percentile, orweight �120% of ideal for height) andhave two of the following risk factors:● Family history of type 2 diabetes in

first- or second-degree relative● Race/ethnicity (Native American, Af-

rican American, Latino, Asian Amer-ican, Pacific Islander)

● Signs of insulin resistance or condi-tions associated with insulin resistance(acanthosis nigricans, hypertension,dyslipidemia, or polycystic ovary syn-drome [PCOS])

● Maternal history of diabetes or gesta-tional diabetes mellitus (GDM) (E)

● Testing should begin at age 10 years orat onset of puberty, if puberty occurs ata younger age, and be repeated every 2years. (E)

● The FPG is the preferred test. (E)

Detection and Diagnosis of GDM● Screen for GDM using risk factor anal-

ysis and, if appropriate, use of anOGTT. (C)

● Women with GDM should be screenedfor diabetes 6–12 weeks postpartumand should be followed up with subse-quent screening for the development ofdiabetes or pre-diabetes. (E)

Prevention/Delay of Type 2 Diabetes● Patients with impaired glucose toler-

ance (IGT) (A) or IFG (E) should begiven counseling on weight loss of5–10% of body weight, as well as onincreasing physical activity to at least150 min per 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 counselingshould be covered by third-party pay-ors. (E)

● In addition to lifestyle counseling, met-formin may be considered in those whoare at very high risk (combined IFG andIGT plus other risk factors) and who areobese and under 60 years of age. (E)

● Monitoring for the development of di-abetes in those with pre-diabetesshould be performed every year. (E)

Self-monitoring of Blood Glucose(SMBG)● SMBG should be carried out three or

more times daily for patients using mul-tiple insulin injections or insulin pumptherapy. (A)

● For patients using less frequent insulininjections, noninsulin therapies, ormedical nutrition therapy (MNT)alone, SMBG may be useful in achiev-ing glycemic goals. (E)

● To achieve postprandial glucose tar-

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Abbreviations: ABI, ankle-brachial index; ADA, American Diabetes Association; ARB, angiotensis recep-tor blocker; CBG, capillary blood glucose; CHD, Coronary heart disease; CKD, chronic kidney disease; CVD,cardiovascular disease; DMMP, diabetes medical management plan; DPN, distal symmetric polyneuropathy;DSME, diabetes self-management education; FPG, fasting plasma glucose; GDM, gestational diabetes mel-litus; GFR, glomerular filtration rate; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; MNT,medical nutrition therapy; NPDR, proliferative diabetic retinopathy; OGTT, oral glucose tolerance test; PAD,peripheral arterial disease; PDR, proliferative diabetic retinopathy; SMBG, self-monitoring of blood glucose;TSH, thryoid-stimulating hormone.

DOI: 10.2337/dc08–S005.© 2008 by the American Diabetes Association.

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DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S5

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 may bea supplemental tool to SMBG for se-lected patients with type 1 diabetes, es-pecially those with hypoglycemiaunawareness. (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● Lowering A1C to an average of �7%

has clearly been shown to reduce mi-crovascular and neuropathic complica-tions of diabetes and, possibly,macrovascular disease. Therefore, theA1C goal for nonpregnant adults ingeneral is �7%. (A)

● Epidemiologic studies have suggestedan incremental (albeit, in absoluteterms, a small) benefit to lowering A1Cfrom 7% into the normal range. There-fore, the A1C goal for selected individ-ual patients is as close to normal (�6%)as possible without significant hypogly-cemia. (B)

● Less stringent A1C goals may be appro-priate for patients with a history of se-vere hypoglycemia, patients withlimited life expectancies, children, in-dividuals with comorbid conditions,and those with longstanding diabetesand minimal or stable microvascularcomplications. (E)

Medical Nutrition Therapy (MNT)General recommendations● Individuals who have pre-diabetes or

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

● MNT should be covered by insuranceand other payors. (E)

Energy balance, overweight, and obesity● 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 or low-fat calorie-restricted dietsmay be effective in the short term (up to1 year). (A)

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

● Physical activity and behavior modifica-tion are important components of weightloss programs and are most helpful inmaintenance of weight loss. (B)

Primary prevention of diabetes● Among individuals at high risk for de-

veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges that include moderate weightloss (7% 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)

Dietary fat intake in diabetes manage-ment● Saturated fat intake should be �7% of

total calories. (A)● Intake of trans fat should be minimized.

(E)

Carbohydrate intake in diabetes man-agement● Monitoring carbohydrate, whether by

carbohydrate counting, exchanges, orexperience-based estimation, remains akey strategy in achieving glycemic con-trol. (A)

● For individuals with diabetes, the use ofthe glycemic index and glycemic loadmay provide a modest additional bene-fit for glycemic control over that ob-served when total carbohydrate isconsidered alone. (B)

Other nutrition recommendations● Sugar alcohols and nonnutritive sweet-

eners are safe when consumed withinthe acceptable daily intake levels estab-lished by the Food and Drug Adminis-tration (FDA). (A)

● If adults with diabetes choose to use alco-hol, daily intake should be limited to amoderate amount (one drink per day orless for adult women and two drinks perday 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)

● Benefit from chromium supplementa-tion in people with diabetes or obesityhas not been conclusively demon-strated and, therefore, cannot be rec-ommended. (E)

Diabetes Self-ManagementEducation (DSME)● People with diabetes should receive

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

● Self-management behavior change isthe key outcome of DSME and shouldbe measured and monitored as part ofcare. (E)

● DSME should address psychosocial is-sues, since emotional well-being isstrongly associated with positive diabe-tes outcomes. (C)

● DSME should be reimbursed by third-party payors. (E)

Physical Activity● People with diabetes should be advised

to perform at least 150 min/week 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

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S6 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

(financial, social, and emotional), andpsychiatric history. (E)

● Screen for psychosocial problems suchas depression, anxiety, eating disor-ders, and cognitive impairment whenadherence to the medical regimen ispoor. (E)

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

treatment for the conscious individualwith 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 in order to partially re-verse hypoglycemia unawareness andreduce risk of future episodes. (B)

Immunization● Annually provide an influenza vaccine

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

● Provide at least one lifetime pneumo-coccal vaccine for adults with diabetes.A one-time revaccination is recom-mended for individuals �65 years ofage previously immunized when theywere �65 years of age if the vaccine wasadministered �5 years ago. Other indi-cations for repeat vaccination includenephrotic syndrome, chronic renal dis-ease, and other immunocompromisedstates, such as after transplantation. (C)

Hypertension/Blood PressureControlScreening 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 �130

mmHg or diastolic blood pressure �80mmHg confirms a diagnosis of hyper-tension. (C)

Goals● Patients with diabetes should be treated

to a systolic blood pressure �130mmHg. (C)

● 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 addition ofpharmacological 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)

● Pharmacologic therapy for patientswith diabetes and hypertension shouldbe with a regimen that includes eitheran ACE inhibitor or an angiotensin re-ceptor blocker (ARB). If one class is nottolerated, the other should be substi-tuted. If needed to achieve blood pres-sure targets, a thiazide diuretic shouldbe added to those with an estimatedglomerular filtration rate (GFR) �50ml/min per 1.73 m2 and a loop diureticfor those with an estimated GFR �50ml/min per 1.73 m2. (E)

● 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 closely moni-tored. (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, andcholesterol intake; weight loss (if indi-cated); and increased physical activityshould be recommended to improvethe lipid profile in patients with diabe-tes. (A)

● Statin therapy should be added to life-style therapy, regardless of baselinelipid levels, for diabetic patients:● with overt cardiovascular disease

(CVD) (A)● without CVD who are over the age of

40 and have one or more other CVDrisk factors. (A)

● For patients at lower risk than thosementioned above (e.g., without overtCVD and under the age of 40), statintherapy should be considered in addi-tion to lifestyle therapy if LDL choles-terol remains �100 mg/dl or in thosewith multiple CVD 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. (E)

● If drug-treated patients do not reach theabove targets on maximal tolerated sta-tin therapy, a reduction in LDL choles-terol of �40% from baseline is analternative therapeutic goal. (A)

● Triglycerides levels �150 mg/dl (1.7mmol/l) and HDL cholesterol levels�40 mg/dl (1.0 mmol/l) in men and�50 mg/dl (1.3 mmol/l) in women aredesirable. However, LDL cholesterol–targeted statin therapy remains the pre-ferred strategy. (C)

● Combination therapy using statins andother lipid-lowering agents may beconsidered to achieve lipid targets buthas not been evaluated in outcomestudies for either CVD outcomes orsafety. (E)

● Statin therapy is contraindicated inpregnancy. (E)

Antiplatelet Agents● Use aspirin therapy (75–162 mg/day)

as a secondary prevention strategy indiabetic individuals with a history ofCVD. (A)

● Use aspirin therapy (75–162 mg/day)as a primary prevention strategy in

Executive Summary

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S7

those with type 1 or type 2 diabetes atincreased cardiovascular risk, includ-ing those who are �40 years of age orwho have additional risk factors (familyhistory of CVD, hypertension, smok-ing, dyslipidemia, or albuminuria). (A)

● Aspirin therapy is not recommended inpeople under 30 years of age, due tolack of evidence of benefit, and is con-traindicated in patients under the age of21 years because of the associated riskof Reye’s syndrome. (E)

● Combination therapy using other anti-platelet agents such as clopidrogel inaddition to aspirin should be used inpatients with severe and progressiveCVD. (C)

● Other antiplatelet agents may be a rea-sonable alternative for high-risk pa-tients with aspirin allergy, withbleeding tendency, who are receivinganticoagulant therapy, with recent gas-trointestinal bleeding, and with clini-cally active hepatic disease who are notcandidates for aspirin therapy. (E)

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, evaluate risk

factors to stratify patients by 10-year risk,and treat risk factors accordingly. (B)

Treatment● In patients with known CVD, ACE in-

hibitor, aspirin, and statin therapy (ifnot contraindicated) should be used toreduce the risk of cardiovascularevents. (A)

● In patients with a prior myocardial in-farction, add �-blockers (if not contra-indicated) to reduce mortality. (A)

● In patients �40 years of age with an-other cardiovascular risk factor (hyper-tension, family history, dyslipidemia,microalbuminuria, cardiac autonomicneuropathy, or smoking), ACE inhibitor,aspirin, and statin therapy (if not contra-indicated) should be used to reduce therisk of cardiovascular events. (B)

● In patients with treated congestiveheart failure (CHF), metformin andthiazolidinedione (TZD) use are con-traindicated. (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 patients,starting 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 inhibitorsand 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 mayimprove measures of renal function(e.g., urine albumin excretion rate andGFR) and is recommended. (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 the re-sponse to therapy and the progressionof disease is recommended. (E)

● Consider referral to a physician experi-enced in the care of kidney diseasewhen there is uncertainty about the eti-ology of kidney disease (active urinesediment, absence of retinopathy, rapiddecline in GFR), difficult managementissues, or advanced kidney disease. (B)

Retinopathy Screening andTreatmentGeneral 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 adolescents with type 1 dia-

betes should have an initial dilated andcomprehensive eye examination by anophthalmologist or optometrist within 5years after the onset 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 exams(every 2–3 years) may be consideredfollowing one or more normal eye ex-ams. Examinations will be requiredmore frequently if retinopathy is pro-gressing. (B)

● Women with preexisting diabetes whoare planning 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 the

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S8 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

management 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 in 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 andTreatment● 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)

● Educate all patients about self-care ofthe feet. For those with DPN, facilitateenhanced foot care education and referfor special footware. (B)

● Screening for signs and symptoms ofautonomic neuropathy should be insti-tuted at diagnosis of type 2 diabetes and5 years after the diagnosis of type 1 di-abetes. Special testing is rarely neededand may not affect management or out-comes. (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 can be accomplished in aprimary care setting and should includethe use of a monofilament, tuning fork,palpation, and a visual examination. (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 witha history 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 adolescentsGlycemic control● Consider age when setting glycemic

goals in children and adolescents withtype 1 diabetes, with less stringent goalsfor younger children. (E)

Nephropathy● Annual screening for microalbumin-

uria, with a random spot urine samplefor microalbumin-to-creatinine ratio,should be initiated once the child is 10years of age and has had diabetes for 5years. (E)

● Confirmed, persistently elevated mi-croalbumin levels on two additionalurine specimens should be treated withan ACE inhibitor, titrated to normaliza-tion of microalbumin 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 appro-priate. If target blood pressure is notreached with 3–6 months of lifestyleintervention, pharmacologic treatmentshould be initiated. (E)

● Pharmacologic treatment of hyperten-sion (systolic or diastolic blood pressureconsistently above the 95th percentile forage, sex, and height or consistently�130/80 mmHg, if 95% exceeds thatvalue) should be initiated as soon as thediagnosis is confirmed. (E)

● ACE inhibitors should be consideredfor the initial treatment of hyperten-sion. (E)

DyslipidemiaScreening● If there is a family history of hypercho-

lesterolemia (total cholesterol �240mg/dl) or a cardiovascular event before

age 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 per-formed at puberty (�10 years). All chil-dren diagnosed with diabetes at or afterpuberty should have a fasting lipid pro-file performed soon after diagnosis(after glucose control has been estab-lished). (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 usinga Step 2 American Heart Association dietaimed at a decrease in the amount of sat-urated fat in the diet. (E)

● After the age of 10 years, the addition ofa statin is recommended in patientswho, after MNT and lifestyle changes,have LDL cholesterol �160 mg/dl (4.1mmol/l) or LDL cholesterol �130mg/dl (3.4 mmol/l) and one or moreCVD risk factors. (E)

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

Retinopathy● The first ophthalmologic examination

should be obtained once the child is 10years of age and has had diabetes for3–5 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● Patients with type 1 diabetes who be-

come symptomatic for celiac diseaseshould be screened, using tissue trans-glutaminase (tTg) antibodies or anti-endomysial antibodies (anti-EMA),with documentation of normal serumimmunoglobulin A (IgA) levels. (E)

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

● Children with confirmed celiac diseaseshould have consultation with a dietitianand be placed on a gluten-free diet. (E)

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DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S9

Hypothyroidism● Patients with type 1 diabetes should be

screened for thyroid peroxidase and thy-roglobulin antibodies at diagnosis. (E)

● Thryoid-stimulating hormone (TSH)concentrations should be measured af-ter metabolic control has been estab-lished. If normal, they should be re-checked every 1–2 years, or if thepatient develops symptoms of thyroiddysfunction, thyromegaly, or an abnor-mal growth rate. Free T4 should bemeasured if TSH is abnormal. (E)

Preconception Care● A1C levels should be as close to normal as

possible (�7%) in an individual patientbefore conception is attempted. (B)

● All women with diabetes and child-bearing potential should be educatedabout the need for good glucose controlbefore pregnancy and should partici-pate in family planning. (E)

● 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 before conception,since drugs commonly used to treat di-abetes and its complications may becontraindicated or not recommendedin pregnancy, including statins, ACEinhibitors, ARBs, and most noninsulintherapies. (E)

Older Adults● Older adults who are functional, cogni-

tively intact, and have significant lifeexpectancy should receive diabetestreatment using goals developed foryounger adults. (E)

● Glycemic goals for older adults not meet-ing the above criteria may be relaxed us-ing individual criteria, but hyperglycemialeading to symptoms or risk of acute hy-perglycemic complications should beavoided in all patients. (E)

● Other cardiovascular risk factors shouldbe treated in older adults with consider-ation of the time frame of benefit and theindividual patient. Treatment of hyper-tension is indicated in virtually all olderadults, and lipid and aspirin therapy maybenefit those with life expectancy at leastequal to the time frame of primary or sec-ondary prevention trials. (E)

● Screening for diabetic complicationsshould be individualized in olderadults, but particular attention should

be paid to complications that wouldlead to functional impairment. (E)

Diabetes Care in the HospitalRecommendations● 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: blood glucose lev-

els should be kept as close to 110 mg/dl(6.1 mmol/l) as possible and generally�140 mg/dl (7.8 mmol/l). (A) Thesepatients require an intravenous insulinprotocol that has demonstrated efficacyand safety in achieving the desired glu-cose range without increasing risk forsevere hypoglycemia. (E)

● Non–critically ill patients: there is noclear evidence for specific blood glu-cose goals. Because cohort data suggestthat outcomes are better in hospitalizedpatients with fasting glucose �126mg/dl and all random glucoses �180–200 mg/dl, these goals are reasonable ifthey can be safely achieved. Insulin isthe preferred drug to treat hyperglyce-mia in most cases. (E)

● Due to concerns regarding the risk ofhypoglycemia, some institutions mayconsider these blood glucose levels tobe overly aggressive for initial targets.Through quality improvement, glyce-mic goals should systematically be re-duced to the recommended levels. (E)

● Scheduled prandial insulin dosesshould be appropriately timed in rela-tion to meals and should be adjustedaccording to point-of-care glucose lev-els. The traditional sliding-scale insulinregimens are ineffective as mono-therapy and are generally not recom-mended. (C)

● Using correction dose or “supplemental”insulin to correct premeal hyperglycemiain addition to scheduled prandial andbasal insulin is recommended. (E)

● Glucose monitoring with orders for cor-rection insulin should be initiated in anypatient not known to be diabetic who re-ceives therapy associated with high riskfor hyperglycemia, including high-doseglucocorticoids therapy, initiation of en-teral or parenteral nutrition, or othermedications such as octreotide or immu-nosuppressive medications. (B) If hyper-

glycemia is documented and persistent,initiation of basal/bolus insulin therapymay be necessary. Such patients shouldbe treated to the same glycemic goals aspatients with known diabetes. (E)

● A plan for treating hypoglycemiashould be established for each patient.Episodes of hypoglycemia in the hospi-tal should be tracked. (E)

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

● A diabetes education plan including“survival skills education” and fol-low-up should be developed for eachpatient. (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)

Diabetes Care in the School and DayCare Setting● An individualized diabetes medical man-

agement plan (DMMP) should be devel-oped by the parent/guardian and thestudent’s diabetes health care team. (E)

● An adequate number of school person-nel should be trained in the necessarydiabetes procedures (including moni-toring of blood glucose levels and theadministration of insulin and glucagon)and in the appropriate response to highand low blood glucose levels. Theseschool personnel need not be healthcare professionals. (E)

● As specified in the DMMP and as devel-opmentally appropriate, the studentwith diabetes should have immediateaccess to diabetes supplies at all times,should be permitted to monitor his orher blood glucose level, and should beable to take appropriate action to treathypoglycemia in the classroom or any-where the student may be in conjunc-tion with a school activity. (E)

Diabetes Care at Diabetes Camps● Each camper should have a standard-

ized medical form completed by his/herfamily and the physician managing thediabetes. (E)

● Camp medical staff should be led by aphysician with expertise in managingtype 1 and type 2 diabetes, and shouldinclude nurses (including diabetes ed-ucators and diabetes clinical nurse spe-cialists) and registered dietitians withexpertise in diabetes. (E)

● All camp staff, including physicians,

Executive Summary

S10 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

nurses, dietitians and volunteers,should undergo background testing toensure appropriateness in workingwith children. (E)

Diabetes Management inCorrectional Institutions● Correctional staff should be trained in

the recognition, treatment, and appro-priate referral for hypo- and hypergly-cemia, including serious metabolicdecompensation. (E)

● Patients with a diagnosis of diabetesshould have a complete medical historyand physical examination by a licensedhealth care provider with prescriptiveauthority in a timely manner upon en-try. Insulin-treated patients shouldhave a capillary blood glucose (CBG)determination within 1–2 h of arrival.Staff should identify patients with type1 diabetes who are at high risk for dia-betic ketoacidosis (DKA) with omissionof insulin. (E)

● Medications and MNT should be con-

tinued without interruption upon entryinto the correctional environment. (E)

● In the correctional setting, policies andprocedures should enable CBG moni-toring to occur at the frequency neces-sitated by the patient’s glycemic controland diabetes regimen, and should re-quire staff to notify a physician of allCBG results outside of a specifiedrange, as determined by the treatingphysician. (E)

● For all inter-institutional transfers, amedical transfer summary should betransferred with the patient, and diabe-tes supplies and medication should ac-company the patient. (E)

● Correctional staff should begin dis-charge planning with adequate leadtime to ensure continuity of care andfacilitate entry into community diabe-tes care. (E)

Emergency and DisasterPreparedness● People with diabetes should maintain a

disaster kit that includes items impor-

tant to their diabetes self-managementand continuing medical care. (E)

● The kit should be reviewed and replen-ished at least twice yearly. (E)

Hypoglycemia andEmployment/Licensure● People with diabetes should be individ-

ually considered for employment basedon the requirements of the specific joband the individual’s medical condition,treatment regimen, and medical his-tory. (E)

Third-Party Reimbursement forDiabetes Care, Self-ManagementEducation, and Supplies● Patients and practitioners should have

access to all classes of antidiabetic med-ications, equipment, and supplies with-out undue controls. (E)

● MNT and DSME should be covered byinsurance and other payors. (E)

Executive Summary

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S11