Standards of Medical Care in Diabetes—2013

American Diabetes Association

doi:10.2337/dc13-S011

Position Statement

Standards of Medical Care in Diabetes—2013

American Diabetes Association

Diabetes Care 2013 Jan; 36(Supplement 1): S11-S66. https://doi.org/10.2337/dc13-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 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
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 Supportive evidence from a well-conducted case-control study
C	Supportive 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
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 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 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^†	<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
Category Spot 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

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

Table 13

Management of CKD in diabetes

GFR	Recommended
All patients	Yearly measurement of creatinine, urinary albumin excretion, potassium
45–60	Referral 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
30–44	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 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)		A1C	Rationale
Values by age (years)	Before meals	Bedtime/overnight	A1C	Rationale
Toddlers and preschoolers (0–6)	100–180	110–200	<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)	90–180	100–180	<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)	90–130	90–150	<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.