Executive Summary: Standards ofMedical Care in Diabetesd2012

Current criteria for thediagnosis of diabetesc 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; or

c fasting plasma glucose (FPG) $126mg/dL (7.0 mmol/l). Fasting is de-fined as no caloric intake for at least8 h; or

c 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 wa-ter; or

c in a patient with classic symptoms ofhyperglycemia or hyperglycemic crisis,a random plasma glucose $200 mg/dL(11.1 mmol/l);

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

Testing for diabetes inasymptomatic patientsc Testing to detect type 2 diabetes and toassess 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 Diabetesd2012”). Inthose without these risk factors, testingshould begin at age 45 years. (B)

c If tests are normal, repeat testing atleast at 3-year intervals is reasonable.(E)

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

c In those identified with increased riskfor future diabetes, identify and, if ap-propriate, treat other cardiovascular dis-ease (CVD) risk factors. (B)

Detection and diagnosis ofgestational diabetesmellitus (GDM)c Screen for undiagnosed type 2 diabetesat the first prenatal visit in those withrisk factors, using standard diagnosticcriteria. (B)

c In pregnant women not previouslyknown to have diabetes, screen forGDM at 24-28 weeks gestation, using a75-g 2-h OGTT and the diagnosticcutpoints in Table 6 of the “Standardsof Medical Care in Diabetesd2012”.(B)

c Screenwomenwith GDM for persistentdiabetes at 6–12 weeks postpartum,using a test other than A1C. (E)

c Women with a history of GDM shouldhave lifelong screening for the devel-opment of diabetes or prediabetes atleast every 3 years. (B)

c Women with a history of GDM foundto have prediabetes should receivelifestyle interventions or metformin toprevent diabetes. (A)

Prevention/delay of type 2diabetesc Patients with IGT (A), IFG (E), or anA1C of 5.7–6.4% (E) should be re-ferred to an effective ongoing sup-port program targeting weight loss of7% of body weight and increasingphysical activity to at least 150 minper week of moderate activity such aswalking.

c Follow-up counseling appears to beimportant for success. (B)

c Based on the cost-effectiveness of dia-betes prevention, such programs shouldbe covered by third-party payers. (B)

c Metformin therapy for prevention oftype 2 diabetes may be considered in

thosewith IGT (A), IFG (E), or anA1Cof5.7–6.4% (E), especially for those withBMI.35 kg/m2, those aged,60 years,and those with prior GDM. (A)

c At least annual monitoring for the de-velopment of diabetes in those withprediabetes is suggested. (E)

Glucose monitoringc Self-monitoring of blood glucose (SMBG)should be carried out three or moretimes daily for patients using multipleinsulin injections or insulin pump ther-apy. (B)

c For patients using less frequent insulininjections, noninsulin therapies, or med-ical nutrition therapy (MNT) alone,SMBG may be useful as a guide to man-agement. (E)

c To achieve postprandial glucose tar-gets, postprandial SMBG may be ap-propriate. (E)

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

c 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)

c Although the evidence for A1C-loweringis less strong in children, teens, andyounger adults, CGM may be helpful inthese groups. Success correlates withadherence to ongoing use of the de-vice. (C)

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

A1Cc Perform the A1C test at least two timesa year in patients who are meeting treat-ment goals (and who have stable glyce-mic control). (E)

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

c Use of point-of-care testing for A1Cprovides the opportunity formore timelytreatment changes. (E)

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

DOI: 10.2337/dc12-s004© 2012 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 thework is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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Glycemic goals in adultsc Lowering A1C to below or around 7%has been shown to reduce microvascularcomplications of diabetes, and if im-plemented soon after the diagnosis ofdiabetes is associated with long-termreduction in macrovascular disease.Therefore, a reasonable A1C goal formany nonpregnant adults is ,7%. (B)

c Providers might reasonably suggest morestringent A1C goals (such as,6.5%) forselected individual patients, if this canbe achieved without significant hypo-glycemia or other adverse effects oftreatment. Appropriate patients mightinclude those with short duration ofdiabetes, long life expectancy, and nosignificant CVD. (C)

c Less stringent A1C goals (such as,8%) may be appropriate for patientswith a history of severe hypoglycemia,limited life expectancy, advanced micro-vascular or macrovascular complications,and extensive comorbid conditions andfor those with longstanding diabetesin whom the general goal is difficult toattain despite diabetes self-managementeducation, appropriate glucose moni-toring, and effective doses of multipleglucose-lowering agents including in-sulin. (B)

Therapy for type 2 diabetesc At the time of type 2 diabetes diagnosis,initiate metformin therapy along withlifestyle interventions, unless metforminis contraindicated. (A)

c In newly diagnosed type 2 diabeticpatients with markedly symptomaticand/or elevated blood glucose levels orA1C, consider insulin therapy, with orwithout additional agents, from the out-set. (E)

c If noninsulin monotherapy at maxi-mal tolerated dose does not achieveor maintain the A1C target over 3–6months, add a secondoral agent, aGLP-1receptor agonist, or insulin. (E)

Medical nutrition therapy(MNT)General Recommendationsc Individuals who have prediabetes ordiabetes should receive individualizedMNT as needed to achieve treatmentgoals, preferably provided by a regis-tered dietitian familiar with the com-ponents of diabetes MNT. (A)

c Because MNT can result in cost-savingsand improvedoutcomes (B),MNTshouldbe adequately covered by insuranceand other payers. (E)

Recommendations for energybalance, overweight, and obesityc Weight loss is recommended for alloverweight or obese individuals whohave or are at risk for diabetes. (A)

c For weight loss, either low-carbohydrate,low-fat calorie-restricted, or Mediterra-nean diets may be effective in the shortterm (up to 2 years). (A)

c For patients on low-carbohydrate di-ets, monitor lipid profiles, renal func-tion, and protein intake (in those withnephropathy) and adjust hypoglyce-mic therapy as needed. (E)

c Physical activity and behavior modi-fication are important components ofweight loss programs and are most help-ful in maintenance of weight loss. (B)

Recommendations for primaryprevention of diabetesc Among individuals at high risk for de-veloping type 2 diabetes, structured pro-grams that emphasize lifestyle changesthat include moderate weight loss (7%body weight) and regular physical ac-tivity (150 min/week), with dietarystrategies that include reduced caloriesand reduced intake of dietary fat, canreduce the risk for developing diabetesand are therefore recommended. (A)

c Individuals at risk for type 2 diabetesshould be encouraged to achieve the U.S.Department of Agriculture (USDA) rec-ommendation for dietaryfiber (14 gfiber/1,000 kcal) and foods containing wholegrains (one-half of grain intake). (B)

c Individuals at risk for type 2 diabetesshould be encouraged to limit theirintake of sugar-sweetened beverages. (B)

Recommendations for managementof diabetesMacronutrients in diabetes managementc The mix of carbohydrate, protein, andfat may be adjusted to meet the meta-bolic goals and individual preferencesof the person with diabetes. (C)

c Monitoring carbohydrate intake, whetherby carbohydrate counting, choices, orexperience-based estimation, remains akey strategy in achieving glycemic con-trol. (B)

c Saturated fat intake should be ,7% oftotal calories. (B)

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

Other nutrition recommendations.c If adults with diabetes choose to usealcohol, they should limit intake to a

moderate amount (one drink per day orless for adult women and two drinks perday or less for adult men) and shouldtake extra precautions to prevent hypo-glycemia. (E)

c Routine supplementation with anti-oxidants, 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)

c It is recommended that individualizedmeal planning include optimization offood choices to meet recommendeddaily allowance (RDA)/dietary referenceintake (DRI) for all micronutrients. (E)

Diabetes self-managementeducation (DSME)c People with diabetes should receiveDSME according to national standardsand diabetes self-management supportat the time their diabetes is diagnosedand as needed thereafter. (B)

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

c DSME should address psychosocial is-sues, since emotional wellbeing is associ-ated with positive diabetes outcomes. (C)

c Because DSME can result in cost-savingsand improved outcomes (B), DSMEshould be adequately reimbursed bythird-party payers. (E)

Physical activityc People with diabetes should be advisedto perform at least 150 min/week ofmoderate-intensity aerobic physical ac-tivity (50–70% of maximum heart rate),spread over at least 3 days per week withno more than 2 consecutive days with-out exercise. (A)

c In the absence of contraindications,people with type 2 diabetes should beencouraged to perform resistance train-ing at least twice per week. (A)

Psychosocial assessmentand carec It is reasonable to include assessmentof the patient’s psychological and so-cial situation as an ongoing part of themedical management of diabetes. (E)

c Psychosocial screening and follow-upmay include, but is not limited to, atti-tudes about the illness, expectations formedical management and outcomes,affect/mood, general and diabetes-relatedquality of life, resources (financial, so-cial, and emotional), and psychiatrichistory. (E)

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Executive Summary

c Consider screening for psychosocial prob-lems such as depression and diabetes-related distress, anxiety, eating disorders,and cognitive impairment when self-management is poor. (C)

Hypoglycemiac Glucose (15–20 g) is the preferred treat-ment for the conscious individual withhypoglycemia, although any form of car-bohydrate that contains glucose may beused. If SMBG 15 min after treatmentshows continued hypoglycemia, the treat-ment should be repeated. Once SMBGglucose returns to normal, the individualshould consume a meal or snack to pre-vent recurrence of hypoglycemia. (E)

c 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)

c 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 hy-poglycemia unawareness and reducerisk of future episodes. (B)

Bariatric surgeryc Bariatric surgery may be considered foradults with BMI.35 kg/m2 and type 2diabetes, especially if the diabetes orassociated comorbidities are difficult tocontrol with lifestyle and pharmaco-logic therapy. (B)

c Patients with type 2 diabetes who haveundergone bariatric surgery need life-long lifestyle support and medical mon-itoring. (B)

c Although small trials have shown glyce-mic benefit of bariatric surgery in patientswith type 2 diabetes and BMI of 30–35 kg/m2, there is currently insufficientevidence to generally recommend sur-gery in patients with BMI ,35 kg/m2

outside of a research protocol. (E)c The long-term benefits, cost-effectiveness,and risks of bariatric surgery in indi-viduals with type 2 diabetes should bestudied inwell-designed controlled trialswith optimal medical and lifestyle ther-apy as the comparator. (E)

Immunizationc Annually provide an influenza vaccineto all diabetic patients $6 months ofage. (C)

c Administer pneumococcal polysaccharidevaccine to all diabetic patients $2 yearsof age. A one-time revaccination is rec-ommended for individuals.64 years ofage previously immunized when theywere ,65 years of age if the vaccinewas administered.5 years ago. Otherindications for repeat vaccination in-clude nephrotic syndrome, chronic renaldisease, and other immunocompro-mised states, such as after transplan-tation. (C)

c Administer hepatitis B vaccination toadults with diabetes as per Centers forDisease Control and Prevention (CDC)recommendations. (C)

Hypertension/bloodpressure controlScreening and diagnosisc Blood pressure should be measured atevery routinediabetes visit. Patients foundto have systolic blood pressure $130mmHg or diastolic blood pressure $80mmHg should have blood pressureconfirmed on a separate day. Repeatsystolic blood pressure$130 mmHg ordiastolic blood pressure $80 mmHgconfirms a diagnosis of hypertension. (C)

Goalsc A goal systolic blood pressure ,130mmHg is appropriate for most patientswith diabetes. (C)

c Based on patient characteristics andresponse to therapy, higher or lowersystolic blood pressure targets may beappropriate. (B)

c Patients with diabetes should be trea-ted to a diastolic blood pressure ,80mmHg. (B)

Treatmentc Patients with a systolic blood pressureof 130–139 mmHg or a diastolic bloodpressure of 80–89 mmHgmay be givenlifestyle therapy alone for a maximumof 3 months and then, if targets are notachieved, may be treated with the ad-dition of pharmacological agents. (E)

c Patients with more severe hypertension(systolic blood pressure $140 or di-astolic blood pressure $90 mmHg) atdiagnosis or follow-up should receivepharmacologic therapy in addition tolifestyle therapy. (A)

c Lifestyle therapy for hypertension con-sists ofweight loss, if overweight; DASH-style dietary pattern, including reducingsodium and increasing potassium in-take; moderation of alcohol intake; andincreased physical activity. (B)

c Patients with diabetes and hypertensionshould be treated with a pharmacologictherapy regimen that includes either anACE inhibitor or an ARB). If one class isnot tolerated, the other should besubstituted. (C)

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

c Administer one or more antihyperten-sive medications at bedtime. (A)

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

c In pregnant patients with diabetes andchronic hypertension, blood pressure tar-get goals of 110–129/65–79 mmHg aresuggested in the interest of long-termmaternal health andminimizing impairedfetal growth. ACE inhibitors and ARBsare contraindicatedduringpregnancy. (E)

Dyslipidemia/lipidmanagementScreeningc In most adult patients, measure fastinglipid profile at least annually. In adultswith low-risk lipid values (LDL choles-terol,100mg/dL,HDL cholesterol.50mg/dL, and triglycerides ,150 mg/dL),lipid assessments may be repeated every2 years. (E)

Treatment recommendationsand goalsc Lifestyle modification focusing on thereduction of saturated fat, trans fat, andcholesterol intake; increase of n-3 fattyacids, viscous fiber and plant stanols/sterols; weight loss (if indicated); andincreased physical activity should berecommended to improve the lipidprofile in patients with diabetes. (A)

c Statin therapy should be added to life-style therapy, regardless of baseline lipidlevels, for diabetic patients:

c with overt CVD. (A)c without CVD who are over the age of40 years and have one or more otherCVD risk factors. (A)

c For lower-risk patients than the above(e.g., without overt CVD and under theage of 40 years), statin therapy shouldbe considered in addition to lifestyletherapy if LDL cholesterol remains.100mg/dL or in those with multiple CVDrisk factors. (E)

c In individuals without overt CVD, theprimary goal is LDL cholesterol ,100mg/dL (2.6 mmol/l). (A)

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c In individuals with overt CVD, a lowerLDL cholesterol goal of ,70 mg/dL(1.8 mmol/l), using a high dose of astatin, is an option. (B)

c If drug-treated patients do not reachthe above targets on maximal toleratedstatin therapy, a reduction in LDL cho-lesterol of;30–40% from baseline is analternative therapeutic goal. (A)

c Triglycerides levels ,150 mg/dL (1.7mmol/l) and HDL cholesterol .40 mg/dL (1.0 mmol/l) in men and.50mg/dL(1.3 mmol/l) in women, are desirable.However, LDL cholesterol–targeted statintherapy remains thepreferred strategy. (C)

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)

c Statin therapy is contraindicated inpregnancy. (B)

Antiplatelet agentsc 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)

c Aspirin should not be recommendedfor CVD prevention for adults withdiabetes at low CVD risk (10-year CVDrisk ,5%, such as in men ,50 yearsand women ,60 years of age with nomajor additional CVD risk factors),since the potential adverse effects frombleeding likely offset the potentialbenefits. (C)

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

c Use aspirin therapy (75–162mg/day) as asecondary prevention strategy in thosewith diabetes with a history of CVD. (A)

c For patients with CVD and documentedaspirin allergy, clopidogrel (75 mg/day)should be used. (B)

c 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 cessationc Advise all patients not to smoke. (A)

c Include smoking cessation counsel-ing and other forms of treatment asa routine component of diabetes care.(B)

Coronary heart disease (CHD)screening and treatmentScreeningc In asymptomatic patients, routine screen-ing for coronary artery disease (CAD) isnot recommended, as it does not im-prove outcomes as long as CVD riskfactors are treated. (A)

Treatmentc In patients with known CVD, considerACE inhibitor therapy (C) and use as-pirin and statin therapy (A) (if notcontraindicated) to reduce the risk ofcardiovascular events. In patients with aprior myocardial infarction, b-blockersshould be continued for at least 2 yearsafter the event. (B)

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

c Avoid TZD treatment in patients withsymptomatic heart failure. (C)

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 screeningand treatmentGeneral recommendationsc To reduce the risk or slow the progres-sion of nephropathy, optimize glucosecontrol. (A)

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

Screeningc Perform an annual test to assess urinealbumin excretion (UAE) in type 1 di-abetic patients with diabetes durationof $5 years and in all type 2 diabeticpatients starting at diagnosis. (B)

c Measure serum creatinine at least annu-ally in all adults with diabetes regardlessof the degree of UAE. The serum creati-nine should be used to estimate glo-merular filtration rate (GFR) and stagethe level of chronic kidney disease(CKD), if present. (E)

Treatmentc In the treatment of the nonpregnant pa-tient with micro- or macroalbuminuria,

either ACE inhibitors or ARBs should beused. (A)

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

c Reduction of protein intake to 0.8–1.0g z kg body wt21 z day21 in individualswith diabetes and the earlier stages ofCKD and to 0.8 g z kg bodywt21 z day21

in the later stages of CKD may improvemeasures of renal function (UAE rate,GFR) and is recommended. (B)

c WhenACE inhibitors, ARBs, or diureticsare used, monitor serum creatinineand potassium levels for the develop-ment of increased creatinine and hy-perkalemia. (E)

c Continuedmonitoring of UAE to assessboth response to therapy and pro-gression of disease is reasonable. (E)

c When estimated GFR (eGFR) is ,60ml z min/1.73 m2

, evaluate and managepotential complications of CKD. (E)

c Consider referral to a physician ex-perienced in the care of kidney dis-ease for uncertainty about the etiologyof kidney disease, difficult manage-ment issues, or advanced kidney dis-ease. (B)

Retinopathy screening andtreatmentGeneral recommendationsc To reduce the risk or slow the pro-gression of retinopathy, optimize gly-cemic control. (A)

c To reduce the risk or slow the progres-sion of retinopathy, optimize blood pres-sure control. (A)

Screeningc Adults and children aged 10 years orolder with type 1 diabetes should havean initial dilated and comprehensiveeye examination by an ophthalmologistor optometrist within 5 years after theonset of diabetes. (B)

c 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)

c 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 ormore normal eye exams.Examinations will be required more fre-quently if retinopathy is progressing. (B)

c High-quality fundus photographs can de-tect most clinically significant diabetic

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Executive Summary

retinopathy. Interpretation of the im-ages shouldbeperformedby a trained eyecare provider. While retinal photogra-phy may serve as a screening tool forretinopathy, it is not a substitute for acomprehensive eye exam, which shouldbe performed at least initially and at in-tervals thereafter as recommended byan eye care professional. (E)

c Women with preexisting diabetes whoare planning pregnancy or who havebecome pregnant should have a com-prehensive eye examination and shouldbe counseled on the risk of developmentand/or progression of diabetic retinopa-thy. Eye examination should occur inthe first trimester with close follow-upthroughout pregnancy and for 1 yearpostpartum. (B)

Treatmentc Promptly refer patients with any levelof macular edema, severe nonproli-ferative diabetic retinopathy (NPDR),or any PDR to an ophthalmologistwho is knowledgeable and experiencedin the management and treatment ofdiabetic retinopathy. (A)

c Laser photocoagulation therapy is in-dicated to reduce the risk of vision lossin patients with high-risk PDR, clini-cally significant macular edema, andsome cases of severe NPDR. (A)

c 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 andtreatementc All patients should be screened fordistal symmetric polyneuropathy (DPN)starting at diagnosis of type 2 diabetesand 5 years after the diagnosis of type 1diabetes and at least annually thereafter,using simple clinical tests. (B)

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

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

c Medications for the relief of specificsymptoms related to painful DPN andautonomic neuropathy are recom-mended, as they improve the quality oflife of the patient. (E)

Foot carec For all patients with diabetes, performan annual comprehensive foot exami-nation to identify risk factors predictiveof ulcers and amputations. The footexamination should include inspec-tion, assessment of foot pulses, andtesting for loss of protective sensation(10-g monofilament plus testing anyone of the following: vibration using128-Hz tuning fork, pinprick sensa-tion, ankle reflexes, or vibration per-ception threshold). (B)

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

c A multidisciplinary approach is rec-ommended for individuals with footulcers and high-risk feet, especiallythose with a history of prior ulcer oramputation. (B)

c 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)

c Initial screening for peripheral arterialdisease (PAD) should include a historyfor claudication and an assessment ofthe pedal pulses. Consider obtainingan ankle-brachial index (ABI), as manypatients with PAD are asymptomatic. (C)

c Refer patients with significant claudi-cation or a positive ABI for further vas-cular assessment and consider exercise,medications, and surgical options. (C)

Assessment of commoncomorbid conditionsc For patients with risk factors, signs orsymptoms, consider assessment and treat-ment for common diabetes-associatedconditions (see Table 15 of the “Stand-ards of Medical Care in Diabetesd2012”). (B)

Children and adolescentsGlycemic controlc Consider agewhen setting glycemic goalsin children and adolescents with type 1diabetes. (E)

Screening and managementof chronic complications inchildren and adolescentswith type 1 diabetesNephropathyc Annual screening for microalbuminuria,with a random spot urine sample foralbumin-to-creatinine ratio (ACR), shouldbe considered once the child is 10

years of age and has had diabetes for 5years. (B)

c Treatmentwith anACE inhibitor, titratedto normalization of albumin excretion,should be considered when elevatedACR is subsequently confirmed ontwo additional specimens from differ-ent days. (E)

Hypertensionc Initial treatment of high-normal bloodpressure (systolic or diastolic bloodpressure consistently above the 90th per-centile for age, sex, and height) includesdietary intervention and exercise, aimedat weight control and increased phys-ical activity, if appropriate. If targetblood pressure is not reached with 3–6months of lifestyle intervention, phar-macologic treatment should be consid-ered. (E)

c Pharmacologic treatment of hyper-tension (systolic or diastolic bloodpressure consistently above the 95thpercentile for age, sex, and height orconsistently .130/80 mmHg, if 95%exceeds that value) should be consid-ered as soon as the diagnosis is con-firmed. (E)

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

c 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)

DyslipidemiaScreeningc If there is a family history of hyper-cholesterolemia or a cardiovascularevent before age 55 years, or if familyhistory is unknown, then considerobtaining a fasting lipid profile onchildren .2 years of age soon afterdiagnosis (after glucose control hasbeen established). If family history isnot of concern, then consider the firstlipid screening at puberty ($10 years).For children diagnosed with diabetesat or after puberty, consider obtaininga fasting lipid profile soon after dia-gnosis (after glucose control has beenestablished). (E)

c For both age-groups, if lipids are abnor-mal, annual monitoring is reasonable. IfLDL cholesterol values are within theaccepted risk levels (,100 mg/dL [2.6mmol/l]), a lipid profile repeated every5 years is reasonable. (E)

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Treatmentc Initial therapy may consist of optimi-zation of glucose control and MNTusing a Step 2 American Heart Associ-ation Diet aimed at a decrease in theamount of saturated fat in the diet. (E)

c After the age of 10 years, the additionof a statin in patients who, after MNTand lifestyle changes, have LDL cho-lesterol .160 mg/dL (4.1 mmol/l), orLDL cholesterol . 30 mg/dL (3.4mmol/l) and one or more CVD riskfactors, is reasonable. (E)

c The goal of therapy is an LDL choles-terol value,100mg/dL (2.6mmol/l). (E)

Retinopathyc The first ophthalmologic examinationshould be obtained once the child is$10 years of age and has had diabetesfor 3–5 years. (B)

c 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 diseasec Consider screening children with type 1diabetes for celiac disease by measur-ing tissue transglutaminase or antiendo-mysial antibodies, with documentationof normal total serum IgA levels, soonafter the diagnosis of diabetes. (E)

c Testing should be considered in chil-dren with growth failure, failure to gainweight, weight loss, diarrhea, flatulence,abdominal pain, or signs of malabsorp-tion, or in children with frequent un-explained hypoglycemia or deteriorationin glycemic control. (E)

c Consider referral to a gastroenterolo-gist for evaluation with endoscopy andbiopsy for confirmation of celiac diseasein asymptomatic children with positiveantibodies. (E)

c Children with biopsy-confirmed celiacdisease should be placed on a gluten-free diet and have consultation with adietitian experienced in managing bothdiabetes and celiac disease. (B)

Hypothyroidismc Consider screening children with type 1diabetes for thyroid disease using thyroidperoxidase and thyroglobulin antibodiessoon after diagnosis. (E)

c Measuring TSH concentrations soonafter diagnosis of type 1 diabetes, aftermetabolic control has been established,is reasonable. If normal, consider re-checking every 1–2 years, especially

if the patient develops symptoms ofthyroid dysfunction, thyromegaly, oran abnormal growth rate. (E)

Transition from pediatric to adult carec As teens transition into emerging adult-hood, health care providers and familiesmust recognize their many vulnerabi-lities (B) and prepare the developingteen, beginning in early to mid adoles-cence and at least one year prior to thetransition. (E)

c Both pediatricians and adult health careproviders should assist in providing sup-port and links to resources for the teenand emerging adult. (B)

Preconception carec A1C levels should be as close tonormal aspossible (,7%) in an individual patientbefore conception is attempted. (B)

c Starting at puberty, preconception coun-seling should be incorporated in theroutine diabetes clinic visit for all womenof childbearing potential. (C)

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

c Medications used by suchwomen shouldbe evaluated prior to conception, sincedrugs commonly used to treat diabetesand its complications may be contra-indicated or not recommended in preg-nancy, including statins, ACE inhibitors,ARBs, andmost noninsulin therapies. (E)

c Since many pregnancies are unplanned,consider the potential risks and benefitsof medications that are contraindicatedin pregnancy in all women of childbear-ing potential, and counsel women usingsuch medications accordingly. (E)

Older adultsc Older adults who are functional, cog-nitively intact, and have significant lifeexpectancy should receive diabetes careusing goals developed for youngeradults. (E)

c Glycemic goals for older adults notmeeting the above criteria may be re-laxed using individual criteria, but hy-perglycemia leading to symptoms or riskof acute hyperglycemic complicationsshould be avoided in all patients. (E)

c Other cardiovascular risk factors shouldbe treated in older adults with consid-eration of the time frame of benefit andthe individual patient. Treatment of hy-pertension is indicated in virtually allolder adults, and lipid and aspirin therapy

may benefit those with life expectancy atleast equal to the time frame of primary orsecondary prevention trials. (E)

c Screening for diabetes complicationsshould be individualized in older adults,but particular attention should be paid tocomplications that would lead to func-tional impairment. (E)

Cystic fibrosis–relateddiabetes (CFRD)c Annual screening for CFRD with OGTTshould begin by age 10 years in all pa-tients with CF who do not have CFRD(B). Use of A1C as a screening test forCFRD is not recommended. (B)

c During a period of stable health thediagnosis of CFRD can be made in CFpatients according to usual diagnosticcriteria. (E)

c Patients with CFRD should be treatedwith insulin to attain individualized gly-cemic goals. (A)

c Annual monitoring for complicationsof diabetes is recommended, beginning5 years after the diagnosis of CFRD. (E)

Diabetes care in the hospitalc All patients with diabetes admitted to thehospital should have their diabetes clearlyidentified in the medical record. (E)

c All patients with diabetes should havean order for blood glucose monitoring,with results available to all membersof the health care team. (E)

c Goals for blood glucose levels:

○ Critically ill patients: Insulin ther-apy should be initiated for treatmentof persistent hyperglycemia startingat a threshold 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 in-travenous insulin protocol that hasdemonstrated efficacy and safety inachieving the desired glucose rangewithout increasing risk for severehypoglycemia. (E)

○ Non–critically ill patients: There isno clear evidence for specific bloodglucose goals. If treated with in-sulin, premeal blood glucose targetsgenerally ,140 mg/dL (7.8 mmol/l)

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Executive Summary

with random blood glucose ,180mg/dL (10.0 mmol/l) are reasonable,provided these targets can be safelyachieved. More stringent targetsmay be appropriate in stable pa-tients with previous tight glycemiccontrol. Less stringent targets may beappropriate in those with severe co-morbidites. (E)

c Scheduled subcutaneous insulin withbasal, nutritional, and correction com-ponents is the preferred method forachieving and maintaining glucose con-trol in noncritically ill patients.

c 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 parenteralnutrition, or other medications such as

octreotide or immunosuppressive medi-cations. (B) If hyperglycemia is docu-mented and persistent, consider treatingsuch patients to the same glycemic goalsas patients with known diabetes. (E)

c A hypoglycemia management protocolshould be adopted and implementedby each hospital or hospital system. Aplan for preventing and treating hy-poglycemia should be established foreach patient. Episodes of hypoglycemiain the hospital should be documentedin the medial record and tracked. (E)

c Consider obtaining an A1C on patientswith diabetes admitted to the hospitalif the result of testing in the previous2–3 months is not available. (E)

c Patients with hyperglycemia in thehospital who do not have a prior di-agnosis of diabetes should have ap-propriate plans for follow-up testingand care documented at discharge. (E)

Strategies for improving carec Care should be aligned with compo-nents of the Chronic Care Model toensure productive interactions be-tween a prepared proactive practiceteam and an informed activated pa-tient. (A)

c When feasible, care systems shouldsupport team-based care, communityinvolvement, patient registries, andembedded decision support tools tomeet patient needs. (B)

c Treatment decisions should be timelyand based on evidence-based guidelinesthat are tailored to individual patientpreferences, prognoses, and comorbid-ities. (B)

c A patient centered communication styleshould be employed that incorporatespatient preferences, assesses literacy andnumeracy, and addresses cultural bar-riers to care. (B)

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