December 28, 2007 -- The American Diabetes Association (ADA) has issued practice guidelines for screening, diagnostic, and therapeutic interventions that are known or believed to improve health outcomes of patients with diabetes. An executive summary published in the January issue of Diabetes Care provides a detailed description of each of the ADA practice recommendations, a grading system developed by the ADA that uses A, B, C, or E to indicate the level of evidence supporting each recommendation, and suggested targets for most patients with diabetes.

"These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care," the guidelines authors write. "While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed."

Specific topic areas covered include diagnosis of diabetes, testing for prediabetes and diabetes, testing for type 2 diabetes in children, detection and diagnosis of gestational diabetes mellitus, prevention and delay of type 2 diabetes, self-monitoring of blood glucose levels, hemoglobin A _1c (A1C) levels, glycemic goals, medical nutrition therapy (MNT), diabetes self-management education (DSME), physical activity, psychosocial assessment and care, hypoglycemia, immunization, hypertension and blood pressure control, and dyslipidemia and lipid management.

Also covered are use of antiplatelet agents, smoking cessation, coronary heart disease screening and treatment, nephropathy screening and treatment, retinopathy screening and treatment, neuropathy screening and treatment, foot care, special issues in treating children and adolescents, preconception care, special issues in treating older adults, diabetes care in the hospital (including goals for blood glucose levels), diabetes care in the school and day care setting, diabetes care at diabetes camps, diabetes management in correctional institutions, emergency and disaster preparedness, hypoglycemia and employment/licensure, and third-party reimbursement for diabetes care, self-management education, and supplies.

Some of the specific recommendations are as follows:

• To diagnose diabetes in children and nonpregnant adults, fasting plasma glucose (FPG) is the preferred test, and use of A1C levels to diagnose diabetes is not currently recommended (E).
• Screening for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults who are overweight or obese (body mass index [BMI] ≥25 kg/m ²) with at least 1 more additional risk factor. Otherwise, testing should begin at age 45 years (B), and if results are normal, testing should be repeated at least at 3-year intervals (E).
• Either an FPG test or 2-hour oral glucose tolerance test (OGTT; 75-g glucose load), or both, is appropriate (B) to test for prediabetes or diabetes, and an OGTT may be considered in patients with impaired fasting glucose (IFG) to better define the risk of diabetes (E).
• Individuals found to have prediabetes should be evaluated and treated, if appropriate, for other cardiovascular risk factors (B).
• To prevent or delay onset of diabetes, patients with impaired glucose tolerance (IGT; A) or IFG (E) should be advised to lose 5% to 10% of body weight and to increase physical activity to at least 150 minutes per week of moderate activity such as walking. Follow-up counseling seems to improve the likelihood of success (B). Because of the potential cost savings associated with diabetes prevention, third-party payors should cover counseling (E).
• Metformin therapy should also be considered in patients who are at very high risk for diabetes, based on combined IFG and IGT plus other risk factors, and who are obese and younger than 60 years of age (E).
• Individuals with prediabetes should be monitored every year for the development of diabetes. (E).
• Because lowering A1C levels to an average of about 7% has been shown to reduce microvascular and neuropathic complications of diabetes and, possibly, macrovascular disease, the target A1c goal for nonpregnant adults is generally less than 7% (A).
• For selected individual patients, the A1C goal is as close to normal (< 6%) as possible without significant hypoglycemia (B), in light of epidemiologic studies showing a small but incremental benefit to lowering A1C from 7% into the normal range.
• For children, patients with a history of severe hypoglycemia, those with limited life expectancies, individuals with comorbid conditions, and those with long duration of diabetes and minimal or stable microvascular complications, less stringent A1C goals may be appropriate (E).
• Individuals with prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, ideally by a registered dietitian who is knowledgeable about diabetes MNT (B). This should be covered by insurance and other payors (E).
• Specific components of MNT should include management of energy balance, overweight, and obesity with diet, physical activity, and behavior modification (B); primary prevention of diabetes among individuals at high risk of developing type 2 diabetes (A); promoting fiber and whole-grain intake meeting US Department of Agriculture recommendations (B); controlling dietary fat intake by limiting saturated fat intake to less than 7% of total calories (A) and minimizing trans fat intake (E); and managing carbohydrate intake.
• Monitoring carbohydrate intake is a key strategy in achieving glycemic control, whether by carbohydrate counting, exchanges, or experience-based estimation (A). For patients with diabetes, glycemic index and glycemic load use may modestly improve glycemic control vs that observed when considering only total carbohydrate (B).
• DSME should be offered to patients with diabetes at the time of diagnosis and as needed thereafter (B), with the goal of changing self-management behavior (E) and addressing psychosocial issues (C). Third-party payors should reimburse for DSME (E).
• People with diabetes should perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50% - 70% of maximum heart rate; [A]), and unless there are contraindications, those with type 2 diabetes should perform resistance training 3 times per week (A).

"People with diabetes should be individually considered for employment based on the requirements of the specific job and the individual's medical condition, treatment regimen, and medical history (E)," the guidelines authors conclude. "Patients and practitioners should have access to all classes of antidiabetic medications, equipment, and supplies without undue controls (E). MNT and DSME should be covered by insurance and other payors (E)."

Diabetes Care. 2008;31(suppl 1):S5-S11.

Clinical Context

Study Highlights

• Antiplatelet agents; smoking cessation; screening for and treatment of coronary heart disease, nephropathy, retinopathy, and neuropathy; foot care; emergency and disaster preparedness; hypoglycemia; and employment and licensure are covered.
• Issues in managing children and adolescents, preconception care, and older adults are covered, as are diabetes care in the hospital, school and day care, diabetes camps, and correctional institutions.
• FPG, not A1C, is the preferred diagnostic test for diabetes in children and nonpregnant adults.
• Screening for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults with a BMI of 25 kg/m² or more and 1 or more other risk factors. Otherwise, testing should begin at age 45 years. If results are normal, testing should be repeated at intervals of 3 years or less.
• FPG or 2-hour OGTT with 75-g glucose load, or both, is appropriate to test for prediabetes or diabetes. OGTT may be considered in patients with IFG to better define the risk for diabetes.
• People with prediabetes should be evaluated and treated for other cardiovascular risk factors.
• To prevent or delay onset of diabetes, patients with IGT or IFG should lose 5% to 10% of body weight and increase physical activity to 150 minutes per week or more of moderate activity. Follow-up counseling improves outcomes and should be covered by third-party payors.
• Metformin therapy should be considered in patients at very high risk for diabetes, based on combined IFG and IGT plus other risk factors, and who are obese and younger than 60 years old.
• People with prediabetes should be monitored yearly for development of diabetes.
• Target A1C goal for nonpregnant adults is generally less than 7%, or less than 6% without significant hypoglycemia, for selected patients.
• Less stringent A1C goals may be appropriate in children and in patients with a history of severe hypoglycemia, limited life expectancy, comorbid conditions, long duration of diabetes, and minimal or stable microvascular complications.
• People with prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, ideally by a registered dietitian knowledgeable in diabetes MNT. This should be covered by insurance and other payors.
• MNT should include management of energy balance, overweight, and obesity with diet, physical activity, and behavior modification; primary prevention of diabetes in high-risk patients; promoting fiber and whole-grain intake; controlling dietary fat intake by limiting saturated fat intake to less than 7% of total calories and minimizing trans fat intake; and managing carbohydrate intake.
• Monitoring carbohydrate intake is a key to glycemic control, whether by carbohydrate counting, exchanges, or experience-based estimation. For patients with diabetes, glycemic index and glycemic load may improve glycemic control vs that observed when considering only total carbohydrate intake.
• DSME should be offered to patients with diabetes at diagnosis and as needed thereafter to change self-management behavior and address psychosocial issues. Third-party payors should reimburse for DSME.
• People with diabetes should perform 150 minutes per week or more of moderate-intensity aerobic physical activity (50% - 70% of maximum heart rate) and resistance training 3 times per week unless contraindicated.
• People with diabetes should be considered for employment based on job requirements, medical condition, treatment regimen, and medical history.
• Patients and clinicians should have access to all classes of antidiabetic medications, equipment, and supplies. MNT and DSME should be covered by insurance and other payors.

Pearls for Practice

• FPG, not A1C, is the preferred diagnostic test for diabetes in children and nonpregnant adults. Screening for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults with a BMI of 25 kg/m² or more and at least 1 other risk factor. Otherwise, testing should begin at age 45 years. If results are normal, testing should be repeated at intervals of 3 years or less. FPG or 2-hour OGTT, or both, is appropriate to test for prediabetes or diabetes.
• The target A1C goal for nonpregnant adults is generally less than 7%, or less than 6% without significant hypoglycemia, for selected patients. Less stringent A1C goals may be appropriate in children and in other specific groups of patients. People with prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals. DSME should be offered to patients with diabetes at diagnosis and as needed thereafter to change self-management behavior and address psychosocial issues. Third-party payors should reimburse for MNT and DSME.

CME/CE Test