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Position Statement

Standards of Medical Care in Diabetes—2012

Diabetes Care 2012 Jan; 35(Supplement 1): S11-S63. https://doi.org/10.2337/dc12-s011
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Article Figures & Tables

Tables

  • Table 1

    ADA evidence grading system for clinical practice recommendations

    Level of evidenceDescription
    AClear evidence from well-conducted, generalizable, RCTs that are adequately powered, including:
    • Evidence from a well-conducted multicenter trial

    • Evidence from a meta-analysis that incorporated quality ratings in the analysis

    Compelling nonexperimental evidence, i.e., “all or none” rule developed by Center for Evidence Based Medicine at Oxford
    Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including:
    • Evidence from a well-conducted trial at one or more institutions

    • Evidence from a meta-analysis that incorporated quality ratings in the analysis

    BSupportive evidence from well-conducted cohort studies
    • Evidence from a well-conducted prospective cohort study or registry

    • Evidence from a well-conducted meta-analysis of cohort studies

    Supportive evidence from a well-conducted case-control study
    CSupportive evidence from poorly controlled or uncontrolled studies
    • Evidence from RCTs with one or more major or three or more minor methodological flaws that could invalidate the results

    • Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)

    • Evidence from case series or case reports

    Conflicting evidence with the weight of evidence supporting the recommendation
    EExpert consensus or clinical experience
  • Table 2
  • Table 3
  • Table 4

    Criteria for testing for diabetes in asymptomatic adult individuals

    1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and who have one or more additional risk factors:
    • physical inactivity

    • first-degree relative with diabetes

    • high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

    • women who delivered a baby weighing >9 lb or who were diagnosed with GDM

    • hypertension (blood pressure ≥140/90 mmHg or on therapy for hypertension)

    • HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

    • women with PCOS

    • A1C ≥5.7%, IGT, or IFG on previous testing

    • other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

    • history of CVD

    2. In the absence of the above criteria, testing for diabetes should begin at age 45 years
    3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more-frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status.
    • ↵* At-risk BMI may be lower in some ethnic groups. PCOS, polycystic ovary syndrome.

  • Table 5

    Testing for type 2 diabetes in asymptomatic children

    Criteria
    • Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height

     Plus any two of the following risk factors:
    • Family history of type 2 diabetes in first- or second-degree relative

    • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)

    • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS, or birth weight small for gestational age birthweight)

    • Maternal history of diabetes or GDM during the child's gestation

     Age of initiation: 10 years or at onset of puberty, if puberty occurs at a younger age
     Frequency: every 3 years
    • PCOS, polycystic ovary syndrome

  • Table 6

    Screening for and diagnosis of GDM

    Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks’ gestation in women not previously diagnosed with overt diabetes.
    The OGTT should be performed in the morning after an overnight fast of at least 8 h.
    The diagnosis of GDM is made when any of the following plasma glucose values are exceeded:
    • Fasting ≥92 mg/dL (5.1 mmol/L)

    • 1 h ≥180 mg/dL (10.0 mmol/L)

    • 2 h ≥153 mg/dL (8.5 mmol/L)

  • Table 7

    Components of the comprehensive diabetes evaluation

    Medical history
    • Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding)

    • Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents

    • Diabetes education history

    • Review of previous treatment regimens and response to therapy (A1C records)

    • Current treatment of diabetes, including medications and medication adherence, meal plan, physical activity patterns, and readiness for behavior change

    • Results of glucose monitoring and patient's use of data

    • DKA frequency, severity, and cause

    • Hypoglycemic episodes

      • ○ Hypoglycemia awareness

      • ○ Any severe hypoglycemia: frequency and cause

    • History of diabetes-related complications

      • ○ Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)

      • ○ Macrovascular: CHD, cerebrovascular disease, PAD

      • ○ Other: psychosocial problems,* dental disease*

    Physical examination
    • Height, weight, BMI

    • Blood pressure determination, including orthostatic measurements when indicated

    • Fundoscopic examination*

    • Thyroid palpation

    • Skin examination (for acanthosis nigricans and insulin injection sites)

    • Comprehensive foot examination

      • ○ Inspection

      • ○ Palpation of dorsalis pedis and posterior tibial pulses

      • ○ Presence/absence of patellar and Achilles reflexes

      • ○ Determination of proprioception, vibration, and monofilament sensation

    Laboratory evaluation
    • A1C, if results not available within past 2–3 months

    • If not performed/available within past year:

      • ○ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides

      • ○ Liver function tests

      • ○ Test for UAE with spot urine albumin-to-creatinine ratio

      • ○ Serum creatinine and calculated GFR

      • ○ Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia, or women over age 50 years

    Referrals
    • Eye care professional for annual dilated eye exam

    • Family planning for women of reproductive age

    • Registered dietitian for MNT

    • DMSE

    • Dentist for comprehensive periodontal examination

    • Mental health professional, if needed

    • ↵* See appropriate referrals for these categories.

  • Table 8
  • Table 9

    Summary of glycemic recommendations for many nonpregnant adults with diabetes

    A1C<7.0%*
    Preprandial capillary plasma glucose70–130 mg/dL* (3.9–7.2 mmol/L)
    Peak postprandial capillary plasma glucose†
    • Goals should be individualized based on*

      • ○ duration of diabetes

      • ○ age/life expectancy

      • ○ comorbid conditions

      • ○ known CVD or advanced microvascular complications

      • ○ hypoglycemia unawareness

      • ○ individual patient considerations

    • More- or less-stringent glycemic goals may be appropriate for individual patients

    • Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals

    <180 mg/dL* (<10.0 mmol/L)
    • †Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

  • Table 10
  • Table 11

    Summary of recommendations for glycemic, blood pressure, and lipid control for most adults with diabetes

    A1C<7.0%*
    Blood pressure<130/80 mmHg†
    Lipids
     LDL cholesterol<100 mg/dL (<2.6 mmol/L)‡
    • *More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, individual and patient considerations.

    • †Based on patient characteristics and response to therapy, higher or lower SBP targets may be appropriate.

    • ‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of a statin, is an option.

  • Table 12

    Definitions of abnormalities in albumin excretion

    CategorySpot collection (μg/mg creatinine)
    Normal<30
    Microalbuminuria30–299
    Macro (clinical)-albuminuria≥300
  • Table 13

    Stages of CKD

    StageDescriptionGFR (ml/min per 1.73 m2 body surface area)
    1Kidney damage* with normal or increased GFR≥90
    2Kidney damage* with mildly decreased GFR60–89
    3Moderately decreased GFR30–59
    4Severely decreased GFR15–29
    5Kidney failure<15 or dialysis
    • ↵* Kidney damage defined as abnormalities on pathologic, urine, blood, or imaging tests. Adapted from ref. 317.

  • Table 14

    Management of CKD in diabetes

    GFRRecommended
    All patientsYearly measurement of creatinine, UAE, potassium
    45-60Referral to nephrology if possibility for nondiabetic kidney disease exists (duration type 1 diabetes <10 years, heavy proteinuria, abnormal findings on renal ultrasound, resistant hypertension, rapid fall in GFR, or active urinary sediment on ultrasound)
    Consider need for dose adjustment of medications
    Monitor eGFR every 6 months
    Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, parathyroid hormone at least yearly
    Assure vitamin D sufficiency
    Consider bone density testing
    Referral for dietary counseling
    30–44Monitor eGFR every 3 months
    Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin, weight every 3–6 months
    Consider need for dose adjustment of medications
    <30Referral to nephrologists
    • Adapted from National Kidney Foundation guidelines (available at http://www.kidney.org/professionals/KDOQI/guideline_diabetes/).

  • Table 15

    Common comorbidities for which increased risk is associated with diabetes

    Hearing impairment
    Obstructive sleep apnea
    Fatty liver disease
    Low testosterone in men
    Periodontal disease
    Certain cancers
    Fractures
    Cognitive impairment
  • Table 16
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Standards of Medical Care in Diabetes—2012
Diabetes Care Jan 2012, 35 (Supplement 1) S11-S63; DOI: 10.2337/dc12-s011

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Diabetes Care Jan 2012, 35 (Supplement 1) S11-S63; DOI: 10.2337/dc12-s011
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  • Article
    • I. CLASSIFICATION AND DIAGNOSIS
    • II. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS
    • III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS (GDM)
    • IV. PREVENTION/DELAY OF TYPE 2 DIABETES
    • V. DIABETES CARE
    • VI. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS
    • VII. ASSESSMENT OF COMMON COMORBID CONDITIONS
    • VIII. DIABETES CARE IN SPECIFIC POPULATIONS
    • IX. DIABETES CARE IN SPECIFIC SETTINGS
    • X. STRATEGIES FOR IMPROVING DIABETES CARE
    • Footnotes
    • References
  • Figures & Tables
  • Suppl Material
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  • Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association
  • Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association
  • Diabetes and Hypertension: A Position Statement by the American Diabetes Association
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