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Position Statement

Standards of Medical Care in Diabetes—2013

  1. American Diabetes Association
Diabetes Care 2013 Jan; 36(Supplement 1): S11-S66. https://doi.org/10.2337/dc13-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 the Centre for Evidence-Based Medicine at the University of Oxford
    Supportive evidence from well-conducted RCTs 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 randomized clinical trials 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 have 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 were diagnosed with GDM
    • hypertension (≥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 polycystic ovary syndrome
    • 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.

  • 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, polycystic ovary syndrome, or small-for-gestational-age birth weight)
    • Maternal history of diabetes or GDM during the child’s gestation
    Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age
    Frequency: every 3 years
    • ↵* Persons aged 18 years and younger.

  • 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 of 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, medication adherence and barriers thereto, 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, and 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 urine albumin excretion with spot urine albumin-to-creatinine ratio
     • Serum creatinine and calculated GFR
     • TSH 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
     • DSME
     • 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†<180 mg/dL* (<10.0 mmol/L)
    •*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
    • ↵†Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

  • Table 10

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

    A1C<7.0%*
    Blood pressure<140/80 mmHg**
    Lipids
    LDL cholesterol<100 mg/dL (<2.6 mmol/L)†
    Statin therapy for those with history of MI or age over 40+ other risk factors
    • ↵* 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, and individual patient considerations.

    • **Based on patient characteristics and response to therapy, lower systolic blood pressure 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 11

    Definitions of abnormalities in albumin excretion

    CategorySpot collection (μg/mg creatinine)
    Normal<30
    Increased urinary albumin excretion*≥30
    • ↵* Historically, ratios between 30 and 299 have been called microalbuminuria and those 300 or greater have been called macroalbuminuria (or clinical albuminuria).

  • Table 12

    Stages of CKD

    StageDescriptionGFR (mL/min/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 pathological, urine, blood, or imaging tests. Adapted from ref. 359.

  • Table 13

    Management of CKD in diabetes

    GFRRecommended
    All patientsYearly measurement of creatinine, urinary albumin excretion, potassium
    45–60Referral to nephrology if possibility for nondiabetic kidney disease exists (duration of 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 nephrologist
    • Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.

  • Table 14

    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
    Depression
  • Table 15

    Plasma blood glucose and A1C goals for type 1 diabetes by age-group

    Values by age (years)Plasma blood glucose goal range (mg/dL)A1CRationale
    Before mealsBedtime/overnight
    Toddlers and preschoolers (0–6)100–180110–200<8.5%• Vulnerability to hypoglycemia
    • Insulin sensitivity
    • Unpredictability in dietary intake and physical activity
    • A lower goal (<8.0%) is reasonable if it can be achieved without excessive hypoglycemia
    School age (6–12)90–180100–180<8%• Vulnerability of hypoglycemia
    • A lower goal (<7.5%) is reasonable if it can be achieved without excessive hypoglycemia
    Adolescents and young adults (13–19)90–13090–150<7.5%• A lower goal (<7.0%) is reasonable if it can be achieved without excessive hypoglycemia
    Key concepts in setting glycemic goals:
    • Goals should be individualized and lower goals may be reasonable based on benefit-risk assessment.
    • Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness.
    • Postprandial blood glucose values should be measured when there is a discrepancy between preprandial blood glucose values and A1C levels and to help assess glycemia in those on basal/bolus regimens.
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Diabetes Care: 36 (Supplement 1)

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Standards of Medical Care in Diabetes—2013
American Diabetes Association
Diabetes Care Jan 2013, 36 (Supplement 1) S11-S66; DOI: 10.2337/dc13-S011

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Standards of Medical Care in Diabetes—2013
American Diabetes Association
Diabetes Care Jan 2013, 36 (Supplement 1) S11-S66; DOI: 10.2337/dc13-S011
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  • Article
    • I. CLASSIFICATION AND DIAGNOSIS
    • II. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS
    • III. DETECTION AND DIAGNOSIS OF GDM
    • IV. PREVENTION/DELAY OF TYPE 2 DIABETES
    • V. DIABETES CARE
    • D. Pharmacological and overall approaches to treatment
    • 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
  • Info & Metrics
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More in this TOC Section

  • 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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