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Introduction

The American Diabetes Association(ADA) has been actively involved in

the development and disseminationof diabetes carestandards, guidelines, andrelated documents for many years. Thesestatements are published in one or moreof the Associations professional journals.This supplement contains the latest updateof the ADAs major position statement,Standards of Medical Care in Diabetes,which contains all of the Associations keyrecommendations. In addition, containedherein are selected position statements oncertain topics not adequately covered inthe Standards. ADA hopes that this is aconvenient and important resource for all

health care professionals who care forpeople with diabetes.

ADA Clinical Practice Recommenda-tions consist of position statements thatrepresent official ADA opinionas denotedby formal review and approval by theProfessional Practice Committee and theExecutive Committee of the Board ofDirectors. Consensus reports and system-atic reviews are not official ADA recom-mendations; however, they are producedunder the auspices of the Association byinvited experts. These publications maybe used by the Professional Practice Com-mittee as source documents to update theStandards.

ADA has adopted the following def-initions for its clinically related reports.

ADA position statement. An officialpoint of view or belief of the ADA.Position statements are issued on scien-tific or medical issues related to diabetes.They may be authored or unauthored andare published in ADA journals and otherscientific/medical publications as appro-priate. Position statements must be re-

viewed and approved by the ProfessionalPractice Committee and, subsequently,by the Executive Committee of the Boardof Directors. ADA position statementsare typically based on a systematic re-view or other review of published litera-ture. They are reviewed on an annual basisand updated as needed. A list of recent

position statements is included on p. e3 ofthis supplement.

ADA scientific statement. A scholarlysynopsis of a topic related to diabetes,which may or may not contain clinical orresearch recommendations. Any recom-mendations included represent the officialpoint of view or belief of the ADA. WorkGroup Reports fall into this category. Sci-entific statements are published in the ADA

journals and other scientific/medical pub-lications as appropriate. Scientific state-ments must be reviewed and approved bythe Professional Practice Committee and,subsequently, by the Executive Committee

of the Board of Directors. A list of recentscientific statements is included on p. e4 ofthis supplement.

Systematic review. A balanced reviewand analysis of the literature on a scien-tific or medical topic related to diabetes.Effective January 2010, technical reviewswere replaced by systematic reviews, forwhich a priori search and inclusion/exclusion criteria are developed and pub-lished. The systematic review provides ascientific rationale for a position state-

ment and undergoes critical peer reviewbefore submission to the ProfessionalPractice Committee for approval. A listof past systematic reviews is included onp. e1 of this supplement.

Consensus report. A comprehensive ex-amination by a panel of experts (i.e., con-sensus panel) of a scientific or medicalissue related to diabetes. Effective January2010, consensus statements were re-named consensus reports. The categorymay also include task force and expertcommittee reports. Consensus reports do

not have the Associations name includedin the title or subtitle and include a dis-claimer in the introduction stating that anyrecommendations are not ADA position. Aconsensus report is typically developedimmediately following a consensus confer-ence at which presentations are made onthe issue under review. The statement

represents the panels collective analysis,evaluation, and opinion at that point in

time based in part on the conferenceproceedings. The need for a consensusreport arises when clinicians or scientistsdesire guidance on a subject for which theevidence is contradictory or incomplete.Once written by the panel, a consensusreport is not subject to subsequent reviewor approval and does not represent official

Association opinion. A list of recent con-sensus reports is included on p. e2 of thissupplement.

Professional Practice Committee. TheAs so ci at io n s Prof ess ion al Practice

Committee is responsible for reviewingADA systematic reviews, scientific state-ments, and position statements, as wellas for overseeing revisionsof thelatter asneeded. Appointment to the Profes-sional Practice Committee is based onexcellence in clinical practice and/orresearch. The committee comprisesphysicians, diabetes educators, regis-tered dietitians, and others who haveexpertise in a range of areas, includingadult and pediatric endocrinology, epi-demiology, and public health, lipid

research, hypertension, and preconcep-tion and pregnancy care. All members ofthe Professional Practice Committee arerequired to disclose potential conflictsof interest (listed on p. S109).

Grading of scientific evidence. Therehas been considerable evolution in theevaluation of scientific evidence and inthe development of evidence-based guide-lines since the ADA first began publishingpractice guidelines. Accordingly, we de-veloped a classification system to grade thequality of scientific evidence supporting

ADA recommendations for all new andrevised ADA position statements.

Recommendations are assigned rat-ings of A, B, or C, depending on thequality of evidence (Table 1). Expertopinion (E) is a separate category forrecommendations in which there is asyet no evidence from clinical trials, inwhich clinical trials may be impractical,or in which there is conflicting evidence.Recommendations with an A rating arebased on large well-designed clini-cal trials or well-done meta-analyses.

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/dc13-S001 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited,theuse iseducationaland notforprofit,and the workis notaltered.See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

care.diabetesjournals.org DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 S1
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Generally, these recommendations havethe best chance of improving outcomeswhen applied to the population to whichthey are appropriate. Recommendations

with lower levels of evidence may beequally important but are not as well sup-ported. The level of evidence supportinga given recommendation is noted either

as a heading for a group of recommenda-tions or in parentheses after a given rec-ommendation.

Of course, evidence is only onecompo-nent of clinical decision making. Clinicianscare for patients, not populations;guidelines must always be interpretedwith the needs of the individual patient

in mind. Individual circumstances,such as comorbid and coexisting dis-eases, age, education, disability, and,above all, patients values and prefer-ences, must also be considered and maylead to different treatment targets andstrategies. Also, conventional evidencehierarchies, such as the one adapted bythe ADA, may miss some nuances thatare important in diabetes care. Forexample, while there is excellent evi-dence from clinical trials supportingthe importance of achieving multiplerisk factor control, the optimal way toachieve this result is less clear. It isdifficult to assess each component ofsuch a complex intervention.

ADA wil l continue to impr ove andupdate the Clinical Practice Recommen-dations to ensure that clinicians, healthplans, and policymakers can continueto rely on them as the most authorita-tive and current guidelines for diabetescare. Our Clinical Practice Recom-mendations are also available on the

Associations website at www.diabetes.org/diabetescare.

Table 1dADA evidence-grading system for clinical practice recommendations

Level of

evidence Description

A Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:c Evidence from a well-conducted multicenter trial

c Evidence from a meta-analysis that incorporated quality ratings in the analysisCompelling nonexperimental evidence, i.e., the all or none rule developed by the Centre for Evidence-Based Medicine at OxfordSupportive evidence from well-conducted randomized controlled trials that are adequately powered, including:

c Evidence from a well-conducted trial at one or more institutions

c Evidence from a meta-analysis that incorporated quality ratings in the analysisB Supportive evidence from well-conducted cohort studies, including:

c Evidence from a well-conducted prospective cohort study or registry

c 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, including:

c Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the resultsc Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)c Evidence from case series or case reports

Conflicting evidence withthe weight of evidence supporting the recommendation

E Expert consensus or cl inical experience

S2 DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 care.diabetesjournals.org

Introduction
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Summary of Revisions for the 2013Clinical Practice Recommendations

Revisions to the Standardsof Medical Care inDiabetesd2013In addition to many small changes relatedto new evidence since the prior year, andto clarify recommendations, the follow-ing sections have undergone more sub-stantive changes:

c Section II.C. Screening for Type 1Diabetes has been revised to includemore specific recommendations.

c Section IV. Prevention/Delay of Type 2Diabetes has been revised to reflect

the importance of screening for andtreating other cardiovascular risk fac-tors.

c Section V.C.a. Glucose Monitoring hasbeen revised to highlight the need forpatients on intensive insulin regimensto do frequent self-monitoring of bloodglucose.

c Section V.D. Pharmacological andOverall Approaches to Treatment hasbeen revised to add a section with morespecific recommendations for insulintherapy in type 1 diabetes.

c

Section V.F. Diabetes Self-ManagementEducation and Support has been revisedto be consistent with the newly revised

National Standards for Diabetes Self-Management Education and Support.c Section V.K. Hypoglycemia has been

revised to emphasize the need to assesshypoglycemia and cognitive functionwhen indicated.

c Section V.M. Immunization has beenupdated to include the new Centers forDisease Control and Prevention (CDC)recommendations for hepatitis B vac-cination for people with diabetes.

c Section VI.A.1. Hypertension/BloodPressure Control has been revised tosuggest that the systolic blood pressure

goal for many people with diabetes andhypertension should be ,140 mmHg,but that lower systolic targets (such as,130 mmHg) may be appropriate forcertain individuals, such as youngerpatients, if it can be achieved withoutundue treatment burden.

c Section VI.A.2. Dyslipidemia/LipidManagement and Table 10 have beenrevised to emphasize the importance ofstatin therapy over particular LDLcholesterol goals in high-risk patients.

c Section VI.B. Nephropathy Screening

and Treatment and Table 11 have beenrevised to highlight increased urinaryalbumin excretion over the terms

micro- andmacroalbuminuria, other thanwhen discussion of past studies requiresthe distinction.

c Section VI.C. RetinopathyScreening andTreatment has been revised to includeantivascular endothelial growth factortherapy for diabetic macular edema.

c Section IX.A. Diabetes Care in theHospital has been revised to include arecommendation to consider obtainingan A1C in patients with risk factors forundiagnosed diabetes who exhibit hy-perglycemia in the hospital.

Revised Position Statementc The position statement Diagnosis and

Classification of Diabetes Mellitus hasbeen revised slightly to add newer in-formation about monogenic forms ofdiabetes.

Revisions to the NationalStandards for DiabetesSelf-Management Educationand Supportc The task force report National Standards

for Diabetes Self-Management Educationand Support represents a major revisioncompleted in 2012.





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Executive Summary: Standards ofMedical Care in Diabetesd2013

Current criteria for thediagnosis of diabetesc A1C $6.5%. The test should be per-

formed in a laboratory using a methodthat is NGSP certified and standardizedto the Diabetes Control and Compli-cations 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 water; 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 hyper-glycemia, result should be confirmedby repeat testing.

Testing for diabetes in

asymptomatic patientsc Testing to detect type 2 diabetes and

prediabetes in asymptomatic peopleshould be considered in adults ofany age who are overweight or obese(BMI $25 kg/m2) and who haveone or more additional risk fac-tors for diabetes (see Table 4 of the Standards of Medical Care inDiabetesd2013). In those withoutthese risk factors, testing should be-gin at age 45 years. (B)

c If testsare normal, repeat testing at least

at 3-year intervals is reasonable. (E)c To test for diabetes or prediabetes, theA1C, FPG, or 75-g 2-h OGTT are ap-propriate. (B)

c In those identified with prediabetes,identify and, if appropriate, treat othercardiovascular disease (CVD) risk fac-tors. (B)

Screening for type 2diabetes in childrenc Testing to detect type 2 diabetes and

prediabetes should be considered inchildren and adolescents who are over-weight and who have two or more ad-ditional risk factors for diabetes (seeTable 5 of the Standards of MedicalCare in Diabetesd2013). (E)

Screening for type 1diabetesc Consider referring relatives of those

with type 1 diabetes for antibody test-ing for risk assessment in the settingof a clinical research study. (E)

Detection and diagnosisof gestational diabetesmellitusc Screen for undiagnosed type 2 diabetes

at the first prenatal visit in those withrisk factors, using standard diagnosticcriteria. (B)

c In pregnant women not previouslyknown to have diabetes, screen forgestational diabetes mellitus (GDM)

at 2428 weeks of gestation, using a75-g 2-h OGTT and the diagnostic cutpoints in Table 6 of the Standards ofMedical Care in Diabetesd2013. (B)

c Screen women with GDM for persistentdiabetes at 612 weeks postpartum,using the OGTT and nonpregnancydiagnostic criteria. (E)

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

c Women with a history of GDM found

to have prediabetes should receivelifestyle interventions or metformin toprevent diabetes. (A)

Prevention/delay of type 2diabetesc Patients with impaired glucose toler-

ance (IGT)(A), impaired fasting glucose

(IFG) (E), or an A1C 5.7

6.4% (E)should be referred to an effective on-going support program targeting weightloss of 7% of body weight and in-creasing physicalactivity to at least 150min/week of moderate activity suchas walking.

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

c Based on thecost-effectiveness of diabetesprevention, such programs should becovered by third-party payers. (B)

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

those with IGT (A), IFG (E), or an A1C5.76.4% (E), especially for those withBMI .35 kg/m2, aged ,60 years, andwomen with prior GDM. (A)

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

c Screening for and treatment of modifi-ablerisk factorsfor CVD is suggested. (B)

Glucose monitoringc Patients on multiple-dose insulin

(MDI) or insulin pump therapy should

do self-monitoring of blood glucose(SMBG) at least prior to meals andsnacks, occasionally postprandially, atbedtime, prior to exercise, when theysuspect low blood glucose, after treat-ing low blood glucose until they arenormoglycemic, and prior to criticaltasks such as driving. (B)

c When prescribed as part of a broadereducational context, SMBG results maybe helpful to guide treatment decisionsand/or patient self-management forpatients using less frequent insulin in-

jections or noninsulin therapies. (E)c When prescribing SMBG, ensure that

patients receive ongoing instructionand regular evaluation of SMBG tech-nique and SMBG results, as well astheir ability to use SMBG data to adjusttherapy. (E)

c Continuous glucose monitoring (CGM)in conjunction with intensive insulinregimens can be a useful tool to lower

A1C in selected adults (aged$25 years)with type 1 diabetes. (A)

c Although the evidence for A1C loweringis less strong in children, teens, and





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younger adults, CGM may be helpful inthese groups. Success correlates with ad-herence to ongoing use of the device. (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

times a year in patients who are meet-ing treatment goals (and who havestable glycemic 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 for moretimely treatment changes. (E)

Glycemic goals in adults

c Lowering A1C to below or around 7%has been shown to reduce microvas-cular complications of diabetes, andif implemented soon after the di-agnosis of diabetes is associated withlong-term reduction in macrovasculardisease. Therefore, a reasonable A1Cgoal for many nonpregnant adults is,7%. (B)

c Providers might reasonably suggestmore stringent A1C goals (such as,6.5%) for selected individual pa-tients, if this can be achieved withoutsignificant hypoglycemia or other ad-verse effects of treatment. Appropriatepatients might include those with shortduration of diabetes, long life expec-tancy, and no significant CVD. (C)

c Less stringent A1C goals (such as,8%) may be appropriate for patientswith a history of severe hypoglycemia,limited life expectancy, advanced mi-crovascular or macrovascular compli-cations, extensive comorbid conditions,and those with long-standing diabetesin whom the general goal is difficult toattain despite diabetes self-management

education (DSME), appropriate glucosemonitoring, and effective doses ofmultiple glucose-lowering agents in-cluding insulin. (B)

Pharmacological and overallapproaches to treatment

Insulin therapy for type 1 diabetesc Most people with type 1 diabetes should

be treated with MDI injections (three tofour injections per day of basal andprandial insulin) or continuous sub-cutaneous insulin infusion (CSII). (A)

c Most people with type 1 diabetesshould be educated in how to matchprandial insulin dose to carbohydrateintake, premeal blood glucose, andanticipated activity. (E)

c Most people with type 1 diabetesshould use insulin analogs to reducehypoglycemia risk. (A)

c Consider screening those with type 1diabetes for other autoimmune dis-eases (thyroid, vitamin B12 deficiency,celiac) as appropriate. (B)

Pharmacological therapy forhyperglycemia in type 2 diabetesc Metformin, if not contraindicated and

if tolerated, is the preferred initialpharmacological agent for type 2 di-abetes. (A)

c In newly diagnosed type 2 diabeticpatients with markedly symptomaticand/or elevated blood glucose levels or

A1C, consider insulin therapy, with orwithout additional agents, from theoutset. (E)

c If noninsulin monotherapy at maximaltolerated dose does not achieve or main-tain the A1C target over 36 months,add a second oral agent, a glucagon-likepeptide-1 (GLP-1) receptor agonist, orinsulin. (A)

c A patient-centered approach should beused to guide choice of pharmacologi-cal agents. Considerations includeefficacy, cost, potential side effects,

effects on weight, comorbidities, hy-poglycemia risk, and patient prefer-ences. (E)

c Due to the progressive nature of type 2diabetes, insulin therapy is eventuallyindicated for many patients with type 2diabetes. (B)

Medical nutrition therapy

General recommendationsc Individuals who have prediabetes or

diabetes should receive individualizedmedical nutrition therapy (MNT) as

needed to achieve treatment goals,preferably provided by a registered di-etitian familiar with the components ofdiabetes MNT. (A)

c Because MNT can result in cost-savingsand improved outcomes (B), MNTshould be adequately covered by in-surance and other payers. (E)

Energy balance, overweight, andobesityc Weight loss is recommended for all

overweight 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 modifi-

cation are important components ofweight loss programs and are mosthelpful in maintenance of weight loss. (B)

Recommendations for primaryprevention of type 2 diabetesc Among individuals at high risk for

developing type 2 diabetes, structuredprograms that emphasize lifestyle changesthat include moderate weight loss (7%body weight) and regular physical activity(150 min/week), with dietary strategiesincluding reduced calories and reducedintake of dietary fat, can reduce the riskfor developing diabetes and are thereforerecommended. (A)

c Individuals at risk for type 2 diabetesshould be encouraged to achieve theU.S. Department of Agriculture (USDA)recommendation for dietaryfiber (14 gfiber/1,000 kcal) and foods contain-ing whole grains (one-half of grainintake). (B)

c Individuals at risk for type 2 diabetesshould be encouraged to limit their

intake of sugar-sweetened beverages(SSBs). (B)

Recommendations for managementof diabetesMacronutrients in diabetes managementc The mix of carbohydrate, protein, and

fat may be adjusted to meet the meta-bolic goals and individual preferencesof the person with diabetes. (C)

c Monitoring carbohydrate, whether bycarbohydrate counting, choices, orexperience-based estimation, remainsa key strategy in achieving glycemiccontrol. (B)

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

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

Other nutrition recommendationsc If adults with diabetes choose to use

alcohol, they should limit intake to amoderate amount (one drink per dayor less for adult women and two drinksper day or less for adult men) and


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should take extra precautions to pre-vent hypoglycemia. (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 individualized

meal planning include optimization offood choices to meet recommended di-etary allowance (RDA)/dietary referenceintake (DRI) for all micronutrients. (E)

Diabetes self-managementeducation and supportc People with diabetes should receive

DSME and diabetes self-managementsupport (DSMS) according to NationalStandards for Diabetes Self-Manage-ment Education and Support whentheir diabetes is diagnosed and as

needed thereafter. (B)c Effective self-management and quality

of life are the key outcomes of DSMEand DSMS and should be measuredand monitored as part of care. (C)

c DSME and DSMS should addresspsychosocial issues, since emotionalwell-being is associated with positivediabetes outcomes. (C)

c DSME and DSMS programs are ap-propriate venues for people with pre-diabetes to receive education andsupport to develop and maintain be-haviors that can prevent or delay the

onset of diabetes. (C)c Because DSME and DSMS can result

in cost-savings and improved out-comes (B), DSME and DSMS should beadequately reimbursed by third-partypayers. (E)

Physical activityc Adults with diabetes should be advised

to perform at least 150 min/week ofmoderate-intensity aerobic physicalactivity (5070% of maximum heartrate), spread over at least 3 days/week

with no more than 2 consecutive dayswithout exercise. (A)

c In the absence of contraindications,adults with type 2 diabetes should beencouraged to perform resistancetraining at least twice per week. (A)

Psychosocial assessmentand carec It is reasonableto include assessment of

the patients psychological and socialsituation as an ongoing part of themedical management of diabetes. (E)

c Psychosocial screening and follow-upmay include, but are not limited to,attitudes about the illness, expectationsfor medical management and out-comes, affect/mood, general and di-abetes-related quality of life, resources(financial, social, and emotional), andpsychiatric history. (E)

c Screen for psychosocial problems suchas depression and diabetes-relateddistress, anxiety, eating disorders,and cognitive impairment when self-management is poor. (B)

Hypoglycemiac Individuals at risk for hypoglycemia

should be asked about symptomaticand asymptomatic hypoglycemia ateach encounter. (C)

c Glucose (1520 g) is the preferredtreatment for the conscious individualwith hypoglycemia, although any formof carbohydrate that contains glucosemay be used. If SMBG 15 min aftertreatment shows continued hypogly-cemia, the treatment should be re-peated. Once SMBG glucose returns tonormal, the individual should con-sume a meal or snack to prevent re-currence of hypoglycemia. (E)

c Glucagon should be prescribed for allindividuals at significant risk of severehypoglycemia, and caregivers or familymembers of these individuals shouldbe instructed on its administration.

Glucagon administration is not limitedto health care professionals. (E)

c Hypoglycemia unawareness or one ormore episodes of severe hypoglycemiashould trigger re-evaluation of thetreatment regimen. (E)

c Insulin-treated patients with hypogly-cemia unawareness or an episode ofsevere hypoglycemia should be advisedto raise their glycemic targets to strictlyavoid further hypoglycemia for at leastseveral weeks, to partially reverse hy-poglycemia unawareness, and to re-duce risk of future episodes. (A)

c Ongoing assessment of cognitive func-tionis suggested withincreased vigilancefor hypoglycemia by the clinician,patient, and caregivers if low cognitionand/or declining cognition is found. (B)

Bariatric surgeryc Bariatric surgery may be considered for

adults with BMI$35 kg/m2 and type 2diabetes, especially if the diabetes orassociated comorbidities are difficult tocontrol with lifestyle and pharmaco-logical therapy. (B)

c Patients with type 2 diabetes who haveundergone bariatric surgery need lifelonglifestyle support and medical monitor-ing. (B)

c Although small trials have shown gly-cemic benefit of bariatric surgery inpatients with type 2 diabetes and BMI3035 kg/m2, there is currently in-

sufficient evidence to generally recom-mend surgery in patients with BMI,35kg/m2 outside of a research protocol. (E)

c The long-term benefits, cost-effectiveness,and risks of bariatric surgery in in-dividuals with type 2 diabetes shouldbestudied in well-designed controlledtrials with optimal medical and lifestyletherapy as the comparator. (E)

Immunizationc Annually provide an influenza vaccine

to all diabetic patients $6 months ofage. (C)

c Administer pneumococcal polysaccha-ride vaccine to all diabetic patients $2years of age. A one-time revaccinationis recommended for individuals .64years of age previously immunizedwhen they were,65 years of age if thevaccine was administered .5 yearsago. Other indications for repeat vac-cination include nephrotic syndrome,chronic renal disease, and other im-munocompromised states, such as af-ter transplantation. (C)

c Administer hepatitis B vaccination to

unvaccinated adults with diabetes whoare aged 19 through 59 years. (C)

c Consider administering hepatitis B vac-cination to unvaccinated adults withdiabetes who are aged$60 years. (C)

Hypertension/bloodpressure control

Screening and diagnosisc Blood pressure should be measured at

every routine visit. Patients found tohave elevated blood pressure shouldhave blood pressure confirmed on a

separate day. (B)Goalsc People with diabetes and hypertension

should be treated to a systolic bloodpressure goal of,140 mmHg. (B)

c Lower systolic targets, such as ,130mmHg, may be appropriate for certainindividuals, such as younger patients, ifit can be achieved without unduetreatment burden. (C)

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


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Treatmentc Patients with a blood pressure.120/80

mmHg should be advised on lifestylechanges to reduce blood pressure. (B)

c Patients with confirmed blood pressure$140/80 mmHg should, in addition tolifestyle therapy, have prompt initia-tion and timely subsequent titration of

pharmacological therapy to achieveblood pressure goals. (B)

c Lifestyle therapy for elevated blood pres-sure consists of weight loss, if overweight;Dietary Approaches to Stop Hyperten-sion (DASH)-style dietary pattern in-cluding reducing sodium and increasingpotassium intake; moderation of alcoholintake; andincreased physical activity. (B)

c Pharmacological therapy for patientswith diabetes and hypertension shouldbe with a regimen that includes eitheran ACE inhibitor or an angiotensinreceptor blocker (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 pressuretargets. (B)

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

c If ACE inhibitors, ARBs, or diureticsare used, serum creatinine/estimatedglomerular filtration rate (eGFR) andserum potassium levels should bemonitored. (E)

c In pregnant patients with diabetes andchronic hypertension, blood pressuretarget goals of 110129/6579 mmHgare suggested in the interest of long-term maternal health and minimizingimpaired fetal growth. ACE inhibitorsand ARBs are contraindicated duringpregnancy. (E)

Dyslipidemia/lipidmanagement

Screeningc In most adult patients with diabetes,

measure fasting lipid profile at leastannually. (B)

c In adults with low-risk lipid values(LDL cholesterol ,100 mg/dL, HDLcholesterol .50 mg/dL, and trigly-cerides,150 mg/dL), lipid assessmentsmay be repeated every 2 years. (E)

Treatment recommendations andgoalsc Lifestyle modification focusing on the

reduction of saturated fat, trans fat, andcholesterol intake; increase of n-3 fatty

acids, 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 baselinelipid levels, for diabetic patients:

c with overt CVD (A)c without CVD who are over the age of

40 years and have one or more otherCVD risk factors (family history ofCVD, hypertension, smoking, dysli-pidemia, or albuminuria). (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 remainsabove 100 mg/dL or in those with

multiple CVD risk factors. (C)c In individuals without overt CVD, the

goal is LDL cholesterol ,100 mg/dL(2.6 mmol/L). (B)

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 LDLcholesterol of;3040% from baselineis an alternative therapeutic goal. (B)

c Triglyceride levels ,150 mg/dL (1.7

mmol/L) and HDL cholesterol .40mg/dL (1.0 mmol/L) in men and .50mg/dL (1.3 mmol/L) in women aredesirable (C). However, LDL choles-teroltargeted statin therapy remainsthe preferred strategy. (A)

c Combination therapy has been shownnot to provide additional cardiovascu-lar benefit above statin therapy aloneand is not generally recommended. (A)

c Statin therapy is contraindicated inpregnancy. (B)

Antiplatelet agentsc Consider aspirin therapy (75162 mg/

day) as a primary prevention strategyinthose with type 1 or type 2 diabetes atincreased cardiovascular risk (10-yearrisk .10%). This includes most menaged .50 years or women aged .60years 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 with

diabetes at low CVD risk (10-year CVDrisk,5%, suchas inmenaged,50 yearsand women aged ,60 years with nomajor additional CVD risk factors), sincethe potential adverse effects from bleed-ing likely offset the potential benefits. (C)

c In patients in these age-groups withmultiple other risk factors (e.g., 10-

year risk 510%), clinical judgment isrequired. (E)

c Use aspirin therapy (75162 mg/day) as asecondary prevention strategy in thosewith diabetes with a history of CVD. (A)

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

c Combination therapy with aspirin(75162 mg/day) and clopidogrel (75mg/day) is reasonable for up to a yearafter an acute coronary syndrome. (B)

Smoking cessationc Advise all patients not to smoke or use

tobacco products. (A)c Include smoking cessation counseling

and other forms of treatment as a routinecomponent of diabetes care. (B)

Coronary heart diseasescreening and treatment

Screeningc In asymptomatic patients, routine

screening for coronary artery disease(CAD) is not recommended, as it doesnot improve outcomes as long as CVDrisk factors are treated. (A)

Treatmentc In patients with known CVD, consider

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

c Avoid thiazolidinedione treatment in pa-

tients with symptomatic heart failure. (C)c Metformin may be used in patients with

stable congestive heart failure (CHF) ifrenal function is normal. It should beavoided in unstable or hospitalizedpatients with CHF. (C)

Nephropathy screening andtreatment

General recommendationsc To reduce the risk or slow the pro-

gression of nephropathy, optimize glu-cose control. (A)


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c To reduce the risk or slow the pro-gressionof nephropathy, optimize bloodpressure control. (A)

Screeningc Perform an annual test to assess urine

albumin excretion in type 1 diabeticpatients with diabetes duration of$5

years and in all type 2 diabetic patientsstarting at diagnosis. (B)c Measure serum creatinine at least an-

nually in all adults with diabetes re-gardless of the degree of urine albuminexcretion. The serum creatinine shouldbe used to estimate glomerular filtra-tion rate (GFR) and stage the levelof chronic kidney disease (CKD), ifpresent. (E)

Treatmentc In the treatment of the nonpregnant

patient with modestly elevated (30

299 mg/day) (C) or higher levels($300 mg/day) of urinary albuminexcretion (A), either ACE inhibitors or

ARBs are recommended.c Reduction of protein intake to 0.81.0

g/kg body wt per day in individualswith diabetes and the earlier stages ofCKD and to 0.8 g/kg body wt per dayin the later stages of CKD may improvemeasures of renal function (urine al-bumin excretion rate, GFR) and isrecommended. (C)

c When ACE inhibitors, ARBs, or diu-retics are used, monitor serum creati-

nine and potassium levels for thedevelopment of increased creatinine orchanges in potassium. (E)

c Continued monitoring of urine albu-min excretion to assess both responseto therapy and progression of disease isreasonable. (E)

c When eGFR is ,60 mL/min/1.73 m2,evaluate and manage potential com-plications of CKD. (E)

c Consider referral to a physicianexperienced in the care of kidneydisease for uncertainty about the eti-

ology of kidney disease, diffi

cultmanagement issues, or advancedkidney disease. (B)

Retinopathy screening andtreatment

General 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 pro-gression of retinopathy, optimize bloodpressure control. (A)

Screeningc Adults and children aged $10 years

with type 1 diabetes should have aninitial dilated and comprehensive eyeexamination by an ophthalmologist oroptometrist within 5 years after theonset of diabetes. (B)

c Patients with type 2 diabetes should

have an initial dilated and compre-hensive eye examination by an oph-thalmologist or optometrist shortlyafter the diagnosis 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 23 years) may be consideredfollowing one or more normal eye ex-ams. Examinations will be requiredmore frequently if retinopathy is pro-gressing. (B)

c High-quality fundus photographs candetect most clinically significant di-abetic retinopathy. Interpretation ofthe images should be performed by atrained eye care provider. While retinalphotography may serve as a screeningtool for retinopathy, it is not a sub-stitute for a comprehensive eye exam,which should be performed at leastinitially and at intervals thereafter asrecommended by an eye care pro-fessional. (E)

c Women withpre-existing diabetes whoare planning pregnancy or who have

become pregnant should have a com-prehensive eye examination and becounseled on the risk of developmentand/or progression of diabetic reti-nopathy. Eye examination should oc-cur in the first trimester with closefollow-up throughout pregnancy andfor 1 year postpartum. (B)

Treatmentc Promptly refer patients with any level

of macular edema, severenonproliferativediabetic retinopathy (NPDR), or anyproliferative diabetic retinopathy (PDR)to an ophthalmologist who is knowl-edgeable and experienced in the man-agement and treatment of diabeticretinopathy. (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, and insome cases of severe NPDR. (A)

c Antivascular endothelial growth fac-tor (VEGF) therapy is indicated for di-abetic macular edema. (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 andtreatment

c 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 neuropathy(CAN) should be instituted at diagnosisof type 2 diabetes and 5 years after thediagnosis of type 1 diabetes. Specialtesting is rarely needed and may notaffect management 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, perform

an annual comprehensive foot exami-nation to identify risk factors predic-tive of ulcers and amputations. The

foot examination should include in-spection, assessment of foot pulses,and testing for loss of protective sen-sation (LOPS) (10-g monofilamentplus testing any one of the following:vibration using 128-Hz tuning fork,pinprick sensation, ankle reflexes, orvibration perception 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 LOPSand structural abnormalities, or have ahistory of prior lower-extremity com-plications to foot care specialists forongoing preventive care and lifelongsurveillance. (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 withPAD areasymptomatic.(C)


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c Refer patients with significant claudica-tion or a positive ABI for further vascularassessment and consider exercise, med-ications, and surgical options. (C)

Assessment of commoncomorbid conditionsc For patients with risk factors, signs,

or symptoms, consider assessmentand treatment for common diabetes-associated conditions (see Table 14 ofthe Standards of Medical Care inDiabetesd2013). (B)

Children and adolescentsc As is the case for all children, children

with diabetes or prediabetes should beencouraged to engage in at least 60 minof physical activity each day. (B)

Type 1 diabetes

Glycemic controlc Consider age when setting glycemic

goals in children and adolescents withtype 1 diabetes. (E)

Screening and managementof chronic complications inchildren and adolescentswith type 1 diabetes

Nephropathyc Annual screening for microalbuminuria,

with a random spot urine sample foralbumin-to-creatinineratio(ACR), should

be considered once the child is 10years of age and has had diabetes for5 years. (B)

c Treatment with an ACE inhibitor, ti-trated to normalization of albumin ex-cretion, should be considered whenelevated ACR is subsequently con-firmed on two additional specimensfrom different days. (E)

Hypertensionc Blood pressure should be measured at

each routine visit. Children found tohave high-normal blood pressure orhypertension should have blood pres-sure confirmed on a separate day. (B)

c Initial treatment of high-normal bloodpressure (systolic or diastolic bloodpressure consistently above the 90thpercentile for age, sex, and height) in-cludes dietary intervention and exer-cise, aimed at weight control andincreased physical activity, if appro-priate. If target blood pressure is notreached with 36 months of lifestyleintervention, pharmacological treat-ment should be considered. (E)

c Pharmacological treatment of hyperten-sion (systolic or diastolic blood pressureconsistently above the 95th percentilefor age, sex, and height or consistently.130/80 mmHg, if 95% exceeds thatvalue) should be considered as soon asthe diagnosis is confirmed. (E)

c ACE inhibitors should be considered

for the initial treatment of hypertension,following appropriate reproductivecounseling due to its potential tera-togenic effects. (E)

c The goal of treatment is a blood pres-sure consistently,130/80 or belowthe 90th percentile for age, sex, andheight, 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 yearsof age). For children diagnosed withdiabetes at or after puberty, considerobtaining a fasting lipid profile soonafter the diagnosis (after glucose con-trol has been established). (E)

c For both age-groups, if lipids are ab-

normal, annual monitoring is reason-able. If LDL cholesterol values are withinthe accepted risk levels (,100 mg/dL[2.6 mmol/L]), a lipid profile repeatedevery 5 years is reasonable. (E)

Treatmentc Initial therapy may consist of optimiza-

tion of glucose control and MNT using aStep 2 American Heart Association(AHA) 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 .130 mg/dL (3.4mmol/L) and one or more CVD riskfactors is reasonable. (E)

c The goal of therapy is an LDL cholesterolvalue,100 mg/dL (2.6 mmol/L). (E)

Retinopathyc The first ophthalmologic examination

should be obtained once the child is$10 years of age and has had diabetesfor 35 years. (B)

c After the initial examination, annual rou-tine follow-up is generally recommended.

Less frequent examinations may be ac-ceptable on the advice of an eye careprofessional. (E)

Celiac diseasec Consider screening children with type 1

diabetes for celiac disease by measuringtissue 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, flatu-lence, abdominal pain, or signs ofmalabsorption or in children with fre-quent unexplained hypoglycemia ordeterioration in glycemic control. (E)

c Consider referral to a gastroenterolo-gist for evaluation with possible en-doscopyand biopsy for confirmation ofceliac disease in asymptomatic childrenwith positive antibodies. (E)

c Children with biopsy-confirmed celiacdisease should be placed on a gluten-freediet andhave consultationwitha dietitianexperienced in managing both diabetesand celiac disease. (B)

Hypothyroidismc Consider screening children with type

1 diabetes for thyroid peroxidase andthyroglobulin antibodies soon afterdiagnosis. (E)

c Measuring thyroid-stimulating hormone

(TSH) concentrations soon afterdiagnosisof type 1 diabetes, after metabolic controlhas been established, is reasonable. Ifnormal, consider rechecking every 12years, especially if the patient developssymptoms of thyroid dysfunction, thyro-megaly, or an abnormal growth rate. (E)

Transition from pediatric toadult carec As teens transition into emerging

adulthood, health care providers andfamilies must recognize their many

vulnerabilities (B) and prepare the de-veloping teen, beginning in early tomid adolescence and at least 1 yearprior to the transition. (E)

c Both pediatricians and adult healthcare providers should assist in pro-viding support and links to resourcesfor the teen and emerging adult. (B)

Preconception carec A1Clevels should be as closeto normal as

possible (,7%) in an individual patientbefore conception is attempted. (B)


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c Starting at puberty, preconceptioncounseling should be incorporated inthe routine diabetes clinic visit for allwomen of childbearing potential. (C)

c Women with diabetes who are con-templating pregnancy should be eval-uated and, if indicated, treated fordiabetic retinopathy, nephropathy,

neuropathy, and CVD. (B)c Medicationsused by such women should

be evaluated prior to conception, sincedrugs commonly used to treat diabet-es and its complications may be con-traindicated or not recommended inpregnancy, including statins, ACE in-hibitors, ARBs, and most noninsulintherapies. (E)

c Since many pregnancies are un-planned, consider the potential risksand benefits of medications that arecontraindicated in pregnancy in allwomen of childbearing potential andcounsel women using such medi-cations accordingly. (E)

Older adultsc Older adults who are functional, cog-

nitively intact, and have significant lifeexpectancy should receive diabetescare with goals similar to those de-veloped for younger adults. (E)

c Glycemic goals for some older adultsmight reasonably be relaxed, using in-dividual criteria, but hyperglycemialeading to symptoms or risk of acutehyperglycemic complications shouldbe avoided in all patients. (E)

c Other cardiovascular risk factorsshould be treated in older adults withconsideration of the time frame ofbenefit and the individual patient.Treatment of hypertension is indicatedin virtually all older adults, and lipidand aspirin therapy may benefit thosewith life expectancy at least equal to thetime frame of primary or secondaryprevention trials. (E)

c Screening for diabetes complications

should be individualized in olderadults, but particular attention shouldbe paid to complications that wouldlead to functional impairment. (E)

Cystic fibrosisrelateddiabetesc Annual screening for cystic fibrosis

related diabetes (CFRD) with OGTTshould begin by age 10 years in allpatients with cysticfibrosis who do nothave CFRD (B). Use of A1C as a

screening test for CFRD is not recom-mended. (B)

c During a period of stable health, thediagnosis of CFRD can be made incystic fibrosis patients according tousual glucose criteria. (E)

c Patients with CFRD should be treatedwith insulin to attain individualized

glycemic goals. (A)c Annual monitoring for complications

of diabetes is recommended, beginning5 years after the diagnosis of CFRD. (E)

Diabetes care in the hospitalc All patients with diabetes admitted to

the hospital should have their diabetesclearly identified in the medical record.(E)

c All patients with diabetes should havean order for blood glucose monitoring,

with results available to all members ofthe health care team. (E)c Goals for blood glucose levels:

c Critically ill patients: Insulintherapy should be initiated fortreatment of persistent hyperglyce-mia starting at a threshold of nogreater than 180 mg/dL (10 mmol/L).Once insulin therapy is started, aglucose range of 140180 mg/dL(7.810 mmol/L) is recommendedfor the majority of critically illpatients. (A)

c More stringent goals, such as 110

140 mg/d L (6.17.8 mmol/L)may be appropriate for selectedpatients, as long as this can be ach-ieved without significant hypoglyce-mia. (C)

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)

c Noncritically ill patients: Thereis no clear evidence for specific

blood glucose goals. If treated withinsulin, the premeal blood glucosetargets generally,140 mg/dL (7.8mmol/L) with random blood glu-cose ,180 mg/dL (10.0 mmol/L)are reasonable, provided these tar-gets can be safely achieved. Morestringent targets may be appropri-ate in stable patients with previoustight glycemic control. Less strin-gent targets may be appropriatein those with severe comorbidi-ties. (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)

c Glucose monitoring should be initiatedin any patient not known to be diabeticwho receives therapy associated with

high risk for hyperglycemia, includinghigh-dose glucocorticoid therapy, ini-tiation of enteral or parenteral nutri-tion, or other medications such asoctreotide or immunosuppressive med-ications (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 medical record and tracked. (E)

c Consider obtaining an A1C on patientswith diabetes admitted to the hospital ifthe result of testing in the previous 23months is not available. (E)

c Consider obtaining an A1C in patientswith risk factors for undiagnosed di-abetes who exhibit hyperglycemia inthe hospital. (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 improvingdiabetes carec Care should be aligned with components

of the Chronic Care Model (CCM) toensure productive interactions betweena prepared proactive practice team andan informed activated patient. (A)

c When feasible, care systems shouldsupport team-based care, community

involvement, patient registries, andembedded decision support tools tomeet patient needs. (B)

c Treatment decisions should be timelyand based on evidence-based guide-lines that are tailored to individualpatient preferences, prognoses, andcomorbidities. (B)

c A patient-centered communicationstyle should be employed that in-corporates patient preferences, assessesliteracy and numeracy, and addressescultural barriers to care. (B)


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Standards of Medical Care inDiabetesd2013AMERICAN DIABETES ASSOCIATION

Diabetes mellitus is a chronic illnessthat requires continuing medical careand ongoing patient self-management

education and support to prevent acutecomplications and to reduce the risk oflong-term complications. Diabetes care iscomplex and requires multifactorial riskreduction strategies beyond glycemic con-trol. A large body of evidence exists thatsupports a range of interventions to improvediabetes outcomes.

These standards of care are intendedto provide clinicians, patients, researchers,payers, and other interested individualswith the components of diabetes care,general treatment goals, and tools to eval-uate the quality of care. Although individ-ual preferences, comorbidities, and otherpatient factors may require modification ofgoals, targets that are desirable for mostpatients with diabetes are provided. Spe-cifically titled sections of the standardsaddress children with diabetes, pregnantwomen, and people with prediabetes.These standards are not intended to pre-clude clinical judgment or more extensiveevaluation and management of the patientby other specialists as needed. For moredetailed information about management ofdiabetes, refer to references (13).

The recommendations included arescreening, diagnostic, and therapeuticactions that are known or believed tofavorably affect health outcomes of patientswith diabetes. A large number of theseinterventions have been shown to be cost-effective (4). A grading system (Table 1),developed by the American Diabetes Asso-

ciation (ADA) and modeled after existingmethods, was utilized to clarify and codifythe evidence that forms the basis for therecommendations. The level of evidencethat supports each recommendation islisted after each recommendation usingthe letters A, B, C, or E.

These standards of care are revisedannually by the ADAs multidisciplinaryProfessional Practice Committee, incor-porating new evidence. For the currentrevision, committee members systemati-cally searched Medline for human stud-ies related to each subsection andpublished since 1 January 2011. Recom-mendations (bulleted at the beginningof each subsection and also listed inthe Executive Summary: Standards of

Medical Care in Diabetesd

2013) wererevised based on new evidence or, insome cases, to clarify the prior recom-mendation or match the strength of thewording to the strength of the evidence.

A table linking the changes in recom-mendations to new evidence can be re-viewed at http://professional.diabetes.org/CPR. As is the case for all positionstatements, these standards of care werereviewed and approved by the ExecutiveCommittee of ADAs Board of Directors,which includes health care professionals,scientists, and lay people.

Feedback from the larger clinicalcommunity was valuable for the 2013revision of the standards. Readers whowish to comment on the Standards ofMedical Care in Diabetesd2013 areinvited to do so at http://professional.diabetes.org/CPR.

Members of the Professional PracticeCommittee disclose all potential finan-cial conflicts of interest with industry.These disclosures were discussed at theonset of the standards revision meeting.Members of the committee, their em-

ployer, and their disclosed conflicts ofinterest are listed in the ProfessionalPractice Committee for the 2013 ClinicalPractice Recommendations table (seep. S109). The ADA funds developmentof the standards and all its position state-ments out of its general revenues and

does not use industry support for thesepurposes.

I. CLASSIFICATION ANDDIAGNOSIS

A. ClassificationThe classification of diabetes includesfour clinical classes:

c Type 1 diabetes (results from b-cell

destruction, usually leading to absoluteinsulin deficiency)c Type 2 diabetes (results from a pro-

gressive insulin secretory defect on thebackground of insulin resistance)

c Other specific types of diabetes due toother causes, e.g., genetic defects inb-cell function, genetic defects in in-sulin action, diseases of the exocrinepancreas (such as cystic fibrosis), anddrug- or chemical-induced (such as inthe treatment of HIV/AIDS or after or-gan transplantation)

c Gestational diabetes mellitus (GDM)

(diabetes diagnosed during pregnancythat is not clearly overt diabetes)

Some patients cannot be clearly clas-sified as type 1 or type 2 diabetic. Clinicalpresentation and disease progression varyconsiderably in both types of diabetes.Occasionally, patients who otherwisehave type 2 diabetes may present withketoacidosis. Similarly, patients with type1 diabetes may have a late onset and slow(but relentless) progression of diseasedespite having features of autoimmune

disease. Such diffi

culties in diagnosis mayoccur in children, adolescents, andadults. The true diagnosis may becomemore obvious over time.

B. Diagnosis of diabetesFor decades, the diagnosis of diabetes wasbased on plasma glucose criteria, eitherthe fasting plasma glucose (FPG) or the2-h value in the 75-g oral glucose toler-ance test (OGTT) (5).

In 2009, an International ExpertCommittee that included representativesof the ADA, the International Diabetes


Originally approved 1988. Most recent review/revision October 2012.DOI: 10.2337/dc13-S011 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited,theuse iseducationaland not forprofit, andthe workis notaltered. Seehttp://creativecommons.org/licenses/by-nc-nd/3.0/ for details.


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Federation (IDF), and the EuropeanAssociation for the Study of Diabetes(EASD) recommended the use of the A1Ctest to diagnose diabetes, with a thresholdof$6.5% (6), and the ADA adopted this

criterion in 2010 (5). The diagnostic testshould be performed using a method thatis certified by the NGSP and standardizedor traceable to the Diabetes Control andComplications Trial (DCCT) reference as-say. Although point-of-care (POC) A1C as-says may be NGSP certified, proficiencytesting is not mandated for performingthe test, so use of these assays for diagnosticpurposes could be problematic.

Epidemiological datasets show a sim-ilar relationship for A1C to the risk ofretinopathy as has been shown for thecorresponding FPG and 2-h PG thresh-olds. The A1C has several advantages tothe FPG and OGTT, including greaterconvenience (since fasting is not required),evidence to suggest greater preanalyticalstability, and less day-to-day perturbationsduring periods of stress and illness. Theseadvantages must be balanced by greatercost, the limited availability of A1C testingin certain regions of the developing world,and the incomplete correlation between

A1C and average glucose in certain indi-viduals. In addition, HbA1c levels may varywith patients race/ethnicity (7,8). Some

have posited that glycation rates differ byrace (with, for example, African Americanshaving higher rates of glycation), but this iscontroversial. A recent epidemiologicalstudy found that, when matched for FPG,

African Americans (with and without dia-betes) indeed had higher A1C than whites,but also had higher levels of fructosamineand glycated albumin and lower levels of1,5 anhydroglucitol, suggesting that theirglycemic burden (particularly postpran-dially) may be higher (9). Epidemiologicalstudies forming the framework for recom-mending use of the A1C to diagnose diabe-tes have all been in adult populations.

Whether the cut point would be the sameto diagnose children or adolescents withtype 2 diabetes is an area of uncertainty(3,10). A1C inaccurately reflects glycemiawith certain anemias and hemoglobinopa-thies. For patients with an abnormal hemo-globin but normal red cell turnover, such assickle cell trait, an A1C assay without inter-ferencefromabnormalhemoglobins shouldbe used (anupdated list is availableat www.ngsp.org/interf.asp). For conditions withabnormal red cell turnover, such as preg-nancy, recent blood loss or transfusion, orsome anemias, the diagnosis of diabetesmust employ glucose criteria exclusively.

The established glucose criteria forthe diagnosis of diabetes (FPG and 2-h

PG) remain valid as well (Table 2). Just asthere is less than 100% concordance be-tween the FPG and 2-h PG tests, there isno perfect concordance between A1C andeither glucose-based test. Analyses of theNational Health and Nutrition Examina-tion Survey (NHANES) data indicate that,assuming universal screening of the un-

diagnosed, the A1C cut point of$6.5%identifies one-third fewer cases of undiag-nosed diabetes than a fasting glucose cutpoint of$126 mg/dL (7.0 mmol/L) (11),and numerous studies have confirmedthat at these cut points the 2-h OGTTvalue diagnoses more screened peoplewith diabetes (12). However, in practice, alarge portion of the diabetic population re-mains unaware of its condition. Thus, thelower sensitivity of A1C at the designatedcut point may well be offset by the test sgreater practicality, and wider application

of a more convenient test (A1C) may actu-ally increase the number of diagnoses made.As with most diagnostic tests, a test

result diagnostic of diabetes should berepeated to rule out laboratory error,unless the diagnosis is clear on clinicalgrounds, such as a patient with a hyper-glycemic crisis or classic symptoms ofhyperglycemia and a random plasmaglucose $200 mg/dL. It is preferablethat the same test be repeated for confir-mation, since there will be a greater likeli-hood of concurrence in this case. Forexample, if the A1C is 7.0% and a repeat

result is 6.8%, the diagnosis of diabetes isconfirmed. However, if two different tests(such as A1Cand FPG) are both above thediagnostic thresholds, the diagnosis of di-abetes is also confirmed.

On the other hand, if two differenttests are available in an individual and theresults are discordant, the test whose resultis above the diagnostic cut point should berepeated, and the diagnosis is made basedon the confirmed test. That is, if a patientmeets the diabetes criterion of the A1C (tworesults$6.5%) but not the FPG (,126 mg/dL or 7.0 mmol/L), or vice versa, that per-son should be considered to have diabetes.

Since there is preanalytical and ana-lytical variability of all the tests, it is alsopossible that when a test whose result wasabove the diagnostic threshold is re-peated, the second value will be belowthe diagnostic cut point. This is leastlikely for A1C, somewhat more likely forFPG, and most likely for the 2-h PG.Barring a laboratory error, such patientsare likely to have test results near themargins of the threshold for a diagnosis.The health care professional might opt to

Table 1dADA evidence grading system for clinical practice recommendations

Level of

evidence Description

A Clear evidence from well-conducted, generalizable RCTs that are adequately

powered, including:c Evidence from a well-conducted multicenter trial

c Evidence from a meta-analysis that incorporated quality ratings in theanalysis

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:c Evidence from a well-conducted trial at one or more institutionsc Evidence from a meta-analysis that incorporated quality ratings in the analysis

B Supportive evidence from well-conducted cohort studiesc Evidence from a well-conducted prospective cohort study or registryc 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 studiesc Evidence from randomized clinical trials with one or more major or three or

more minor methodological flaws that could invalidate the resultsc Evidence from observational studies with high potentialfor bias (such as case

series with comparison with historical controls)c Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E Expert consensus or cl inical experience


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follow the patient closely and repeat thetesting in 36 months.

The current diagnostic criteria fordiabetes are summarized in Table 2.

C. Categories of increased riskfor diabetes (prediabetes)In 1997 and 2003, the Expert Committee

on Diagnosis and Classification of Diabe-tes Mellitus (13,14) recognized an inter-mediate group of individuals whoseglucose levels, although not meeting cri-teria for diabetes, are nevertheless toohigh to be considered normal. These per-sons were defined as having impaired fast-ing glucose (IFG) (FPG levels 100 mg/dL[5.6 mmol/L] to 125 mg/dL [6.9 mmol/L])or impaired glucose tolerance (IGT) (2-hvalues in the OGTT of 140 mg/dL [7.8mmol/L] to 199 mg/dL [11.0 mmol/L]). Itshould be noted that the World Health

Organization (WHO) and a number ofother diabetes organizations definethe cut-off for IFG at 110 mg/dL (6.1 mmol/L).

Individuals with IFG and/or IGT havebeen referred to as having prediabetes,indicating the relatively high risk for thefuture development of diabetes. IFG andIGT should not be viewed as clinicalentities in their own right but rather riskfactorsfor diabetes as wellas cardiovasculardisease (CVD). IFG and IGT are associatedwith obesity (especially abdominal or vis-ceral obesity), dyslipidemia with high tri-glycerides and/or low HDLcholesterol, and

hypertension.As is the case with the glucose mea-

sures, several prospective studies that

used A1C to predict the progression todiabetes demonstrated a strong, continu-ous association between A1C and sub-sequent diabetes. In a systematic review of44,203 individuals from 16 cohort stud-ies with a follow-up interval averaging 5.6years (range 2.812 years), those with an

A1C between 5.5 and 6.0% had a substan-

tially increased risk of diabetes with 5-yearincidences ranging from 9 to 25%. An A1Crange of 6.06.5% had a 5-year risk of de-veloping diabetes between 25 to 50% andrelativerisk (RR) 20 times highercomparedwith an A1Cof 5.0% (15). In a community-based study of black and white adultswithout diabetes, baseline A1C was astronger predictor of subsequent diabetesand cardiovascular events than was fast-ing glucose (16). Other analyses suggestthat an A1C of 5.7% is associated withdiabetes risk similar to that in the high-

risk participants in the Diabetes PreventionProgram (DPP) (17).Hence, it is reasonable to consider an

A1C range of 5.76.4% as identifying in-dividuals with prediabetes. As is the casefor individuals found to have IFG andIGT, individuals with an A1C of 5.76.4%should be informed of their increased riskfor diabetes as well as CVD and counseledabout effective strategies to lower their risks(see Section IV). As with glucose measure-ments, the continuum of risk is curvilinear,so that as A1C rises, the risk of diabetes risesdisproportionately (15). Accordingly, inter-

ventions should be most intensive andfollow-up particularly vigilant for thosewith A1Cs above 6.0%, who should be con-sidered to be at very high risk.

Table 3 summarizes the categories ofprediabetes.

II. TESTING FOR DIABETES INASYMPTOMATIC PATIENTS

Recommendationsc Testing to detect type 2 diabetes and

prediabetes in asymptomatic peopleshould be considered in adults of anyage who are overweight or obese (BMI$25 kg/m2) and who have one or moreadditional risk factors for diabetes (Table4). In those without these risk factors,testing should begin at age 45. (B)

c If testsare normal, repeat testing at leastat 3-year intervals is reasonable. (E)

c To test for diabetes or prediabetes, theA1C, FPG, or 75-g 2-h OGTT are appro-priate. (B)

c In those identified with prediabetes,identify and, if appropriate, treat otherCVD risk factors. (B)

For many illnesses, there is a major dis-tinction between screening and diagnostictesting. However, for diabetes, the sametests would be used for screening as fordiagnosis. Diabetes may be identified any-where along a spectrum of clinical scenar-

ios ranging from a seemingly low-riskindividual who happens to have glucosetesting, to a higher-risk individual whomthe provider tests because of high suspicionof diabetes, to the symptomatic patient.The discussion herein is primarily framedas testing for diabetes in those withoutsymptoms. The same assays used for test-ing for diabetes will also detect individualswith prediabetes.

A. Testing for type 2 diabetes andrisk of future diabetes in adultsPrediabetes and diabetes meet established

criteria for conditions in which early de-tection is appropriate. Both conditions arecommon, increasing in prevalence, andimpose significant public health burdens.There is a long presymptomatic phasebefore the diagnosis of type 2 diabetes isusually made. Relatively simple tests areavailable to detect preclinical disease. Ad-ditionally, the duration of glycemic burdenis a strong predictor of adverse outcomes,and effective interventions exist to preventprogression of prediabetes to diabetes (seeSection IV) and to reduce risk of compli-cations of diabetes (see Section VI).

Type 2 diabetes is frequently not di-agnosed until complications appear, andapproximately one-fourth of all peoplewith diabetes in the U.S. may be undiag-nosed. The effectiveness of early identifica-tion of prediabetes and diabetes throughmass testing of asymptomatic individualshas not been proven definitively, andrigorous trials to provide such proof areunlikely to occur. In a large randomizedcontrolled trial (RCT) in Europe, generalpractice patients between the ages of 4069 years were screened for diabetes and

Table 2dCriteria for the diagnosis ofdiabetes

A1C $6.5%. The test should be performed in

a laboratory using a method that is NGSP

certified and standardized to the DCCT

assay.*

OR

FPG $126 mg/dL (7.0 mmol/L). Fasting is

defined as no caloric intake for at least 8 h.*

OR2-h plasma glucose$200 mg/dL (11.1 mmol/L)

during an OGTT. The test should be

performed as described by the WHO, using

a glucose load containing the equivalent of

75 g anhydrous glucose dissolved in water.*

OR

In a patient with classic symptoms of

hyperglycemia or hyperglycemic crisis,

a random plasma glucose $200 mg/dL

(11.1 mmol/L).

*In the absence of unequivocal hyperglycemia, re-sult should be confirmed by repeat testing.

Table 3dCategories of increased risk fordiabetes (prediabetes)*

FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL

(6.9 mmol/L) (IFG)

OR

2-h plasmaglucose in the75-g OGTT 140mg/dL

(7.8 mmol/L) to 199 mg/dL (11.0 mmol/L)

(IGT)

ORA1C 5.76.4%

*For all three tests, risk is continuous, extending be-low the lower limit of the range and becoming dis-proportionately greater at higher ends of the range.


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then randomly assigned by practice toroutine care of diabetes or intensive treat-ment of multiple risk factors. After 5.3years of follow-up, CVD risk factors weremodestly but significantly more improvedwith intensive treatment. Incidence offirstCVD event and mortality rates were notsignificantly different between groups

(18). This study would seem to add sup-port for early treatment of screen-detecteddiabetes, as risk factor control was excel-lent even in the routine treatment armand both groups had lower event ratesthan predicted. The absence of a controlunscreened arm limits the ability to defi-nitely prove that screening impacts out-comes. Mathematical modeling studiessuggest that screening independent ofrisk factors beginning at age 30 yearsor age 45 years is highly cost-effective(,$11,000 per quality-adjusted life-

year gained) (19).Recommendations for testing for di-abetes in asymptomatic, undiagnosedadults are listed in Table4. Testing shouldbe considered in adults of any age withBMI $25 kg/m2 and one or more of theknown risk factors for diabetes. In addi-tion to the listed risk factors, certain med-ications, such as glucocorticoids andantipsychotics (20), are known to in-crease the risk of type 2 diabetes. Thereis compelling evidence that lower BMI cutpoints suggest diabetes risk in some racialand ethnic groups. In a large multiethnic

cohort study, for an equivalent incidencerate of diabetes conferred by a BMI of 30kg/m2 in whites, the BMI cutoff value was

24 kg/m2 in South Asians, 25 kg/m2 inChinese, and 26 kg/m2 in African Ameri-cans (21). Disparities in screening rates,not explainable by insurance status, arehighlighted by evidence that despitemuch higher prevalence of type 2 diabe-tes, non-Caucasians in an insured popu-lation are no more likely than Caucasians

to be screened for diabetes (22). Becauseage is a major risk factor for diabetes, test-ing of those without other risk factorsshould begin no later than age 45 years.

The A1C, FPG, or the 2-h OGTT areappropriate for testing. It should be notedthat the tests do not necessarily detectdiabetes in the same individuals. Theefficacy of interventions for primary pre-vention of type 2 diabetes (2329) hasprimarily been demonstrated among in-dividuals with IGT, not for individualswith isolated IFG or for individuals with

specifi

c A1C levels.The appropriate interval betweentests is not known (30). The rationalefor the 3-year interval is that false nega-tives will be repeated before substantialtime elapses, and there is little likelihoodthat an individual will develop significantcomplications of diabetes within 3 yearsof a negative test result. In the modelingstudy, repeat screening every 3 or 5 yearswas cost-effective (19).

Because of the need for follow-up anddiscussion of abnormal results, testingshould be carried out within the health

care setting. Community screening outsidea health care setting is not recommendedbecause people with positive tests may not

seek, or haveaccess to,appropriatefollow-uptesting and care. Conversely, there may befailure to ensure appropriate repeat testingfor individuals who test negative. Commu-nity screening may also be poorly targeted; i.e., it may fail to reach the groups most at riskandinappropriately test those at lowrisk (theworried well) or even those already diag-

nosed.

B. Screening for type 2 diabetesin children

Recommendationsc Testing to detect type 2 diabetes and

prediabetes should be considered in chil-drenand adolescents who are overweightand who have two or more additionalrisk factors for diabetes (Table 5). (E)

The incidence of type 2 diabetes in

adolescents has increased dramatically inthe last decade, especially in minoritypopulations (31), although the diseaseremains rarein the general pediatric pop-ulation (32). Consistent with recom-mendations for adults, children andyouth at increased risk for the presenceor the development of type 2 diabetesshould be tested within the health caresetting (33). The recommendations ofthe ADA consensus statement Type 2Diabetes in Children and Adolescents,with some modifications, are summa-rized in Table 5.

C. Screening for type 1 diabetesRecommendations

c Consider referring relatives of thosewith type 1 diabetes for antibody test-ing for risk assessment in the settingof a clinical research study. (E)

Generally, people with type 1 diabetespresent with acute symptoms of diabetesand markedly elevated blood glucoselevels, and some cases are diagnosed withlife-threatening ketoacidosis. Evidencefrom several studies suggests that mea-surement of islet autoantibodies in rela-tives of those with type 1 diabetesidentifies individuals who are at risk fordeveloping type 1 diabetes. Such testing,coupled with education about symptomsof diabetes and follow-up in an observa-tional clinical study, may allow earlieridentification of onset of type 1 diabetesand lessen presentation with ketoacidosisat time of diagnosis. This testing may beappropriate in those who have relativeswith type 1 diabetes, in the context of

Table 4dCriteria 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:

c physical inactivity

c first-degree relative with diabetes

c high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian

American, Pacific Islander)

c women who delivered a baby weighing .9 lb or were diagnosed with GDM

c hypertension ($140/90 mmHg or on therapy for hypertension)c HDL cholesterol level ,35 mg/dL (0.90 mmol/L) and/or a triglyceride

level.250 mg/dL (2.82 mmol/L)

c women with polycystic ovary syndrome

c A1C $5.7%, IGT, or IFG on previous testing

c other clinical conditions associated with insulin resistance (e.g., severe obesity,

acanthosis nigricans)

c 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.


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clinical research studies (see, for example,http://www.diabetestrialnet.org). However,widespread clinical testing of asymptomaticlow-risk individuals cannot currently berecommended, as it would identify veryfew individuals in the general populationwho are at risk. Individuals who screenpositive should be counseled about theirrisk of developing diabetes and symptomsof diabetes, followed closely to prevent de-velopment of diabetic ketoacidosis, andinformed about clinical trials. Clinicalstudies are being conducted to test variousmethods of preventing type 1 diabetes inthose with evidence of autoimmunity.Some interventions have demonstratedmodest efficacy in slowing b-cell loss early

in type 1 diabetes (34,35), and further re-search is needed to determine whetherthey may be effective in preventing type1 diabetes.

III. DETECTION ANDDIAGNOSIS OF GDM

Recommendationsc Screen for undiagnosed type 2 diabetes

at the first prenatal visit in those withrisk factors, using standard diagnostic

criteria. (B)c In pregnant women not previously

known to have diabetes, screen for

GDM at 2428 weeks of gestation,using a 75-g 2-h OGTT and the di-agnostic cut points in Table 6. (B)

c Screen women with GDM for persistentdiabetes at 612 weeks postpartum,using the OGTT and nonpregnancydiagnostic criteria. (E)

c Women with a history of GDM shouldhave lifelong screening for the de-velopment 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)

For many years, GDM was defined as

any degree of glucose intolerance withonset or first recognition during preg-nancy (13), whether or not the conditionpersisted after pregnancy, and not ex-cluding the possibility that unrecognizedglucose intolerance may have antedatedor begun concomitantly with the preg-nancy. This definition facilitated a uniformstrategy for detection and classification ofGDM, but its limitations were recognizedfor many years. As the ongoing epidemicof obesity and diabetes has led to moretype 2 diabetes in women of childbearing

age, the number of pregnant women withundiagnosed type 2 diabetes has increased(36). Because of this, it is reasonable to

screen women with risk factors for type2 diabetes (Table 4) for diabetes at theirinitial prenatal visit, using standard diag-nostic criteria (Table 2). Women with di-abetes found at this visit should receivea diagnosis of overt, not gestational,diabetes.

GDM carries risks for the mother and

neonate. The Hyperglycemia and Ad-verse Pregnancy Outcome (HAPO) study(37), a large-scale (;25,000 pregnantwomen) multinational epidemiologicalstudy, demonstrated that risk of adversematernal, fetal, and neonatal outcomescontinuously increased as a function ofmaternal glycemia at 2428 weeks, evenwithin ranges previously considered nor-mal for pregnancy. For most complica-tions, there was no threshold for risk.These results have led to careful recon-sideration of the diagnostic criteria for

GDM. After deliberations in 2008

2009, the International Association ofDiabetes and Pregnancy Study Groups(IADPSG), an international consensusgroup with representatives from multipleobstetrical and diabetes organizations,including ADA, developed revised rec-ommendations for diagnosing GDM.The group recommended that all womennot known to have prior diabetesundergo a 75-g OGTT at 2428 weeksof gestation. Additionally, the group de-veloped diagnostic cut points for the fast-ing, 1-h , and 2-h p lasma glu cose

measurements that conveyed an oddsratio for adverse outcomes of at least1.75 compared with women with themean glucose levels in the HAPO study.Current screening and diagnostic strate-gies, based on the IADPSG statement(38), are outlined in Table 6.

These new criteria will significantlyincrease the prevalence of GDM, primar-ily because only one abnormal value, nottwo, is sufficient to make the diagnosis.The ADA recognizes the anticipated sig-nificant increase in the incidence of GDMdiagnosed by these criteria and is sensitiveto concerns about the medicalization ofpregnancies previously categorized as nor-mal. These diagnostic criteria changes arebeing made in the context of worrisomeworldwide increases in obesity and diabe-tes rates, with the intent of optimizing ges-tational outcomes for women and theirbabies.

Admittedly, there are few data fromrandomized clinical trials regarding ther-apeutic interventions in women who willnow be diagnosed with GDM based ononly one blood glucose value above the

Table 5dTesting for type 2 diabetes in asymptomatic children*

Criteria

c Overweight (BMI .85th percentile for age and sex, weight for height .85th

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