Standards of Medical Care in Diabetes—2012

doi:10.2337/dc12-s011

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

Article Figures & Tables

Tables

Table 1

ADA evidence grading system for clinical practice recommendations

Level of evidence	Description
A	Clear 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
A	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
B	Supportive 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
B	Supportive evidence from a well-conducted case-control study
C	Supportive 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
C	Conflicting evidence with the weight of evidence supporting the recommendation
E	Expert consensus or clinical experience

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 9

Summary of glycemic recommendations for many nonpregnant adults with diabetes

A1C	<7.0%*
Preprandial capillary plasma glucose	70–130 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 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
Category Spot collection (μg/mg creatinine)
Normal <30
Microalbuminuria 30–299
Macro (clinical)-albuminuria ≥300

Table 13

Stages of CKD

Stage	Description	GFR (ml/min per 1.73 m² body surface area)
1	Kidney damage^* with normal or increased GFR	≥90
2	Kidney damage^* with mildly decreased GFR	60–89
3	Moderately decreased GFR	30–59
4	Severely decreased GFR	15–29
5	Kidney 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

GFR	Recommended
All patients	Yearly measurement of creatinine, UAE, potassium
45-60	Referral 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
30–44	Monitor 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
<30	Referral 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