iabetes is a chronic illness that re-quires continuing medical care andongoing patient self-managementeducation and support to prevent acutecomplications and to reduce the risk of long-term complications. Diabetes care iscomplex and requires that many issues,beyondglycemiccontrol,beaddressed.Alarge body of evidence exists that sup-ports a range of interventions to improvediabetes outcomes.These standards of care are intendedto provide clinicians, patients, research-ers, payors, and other interested individ-uals with the components of diabetescare, general treatment goals, and tools toevaluate the quality of care. While indi-vidual preferences, comorbidities, andother patient factors may require modiﬁ-cation of goals, targets that are desirablefor most patients with diabetes are pro-vided. These standards are not intendedtoprecludeclinicaljudgmentormoreex-tensiveevaluationandmanagementofthepatientbyotherspecialistsasneeded.Formoredetailedinformationaboutmanage-ment of diabetes, refer to references 1–3.The recommendations included arescreening,diagnostic,andtherapeuticac-tions that are known or believed to favor-ably affect health outcomes of patientswithdiabetes.Agradingsystem(Table1),developed by the American Diabetes As-sociation (ADA) and modeled after exist-ing methods, was used to clarify andcodify the evidence that forms the basisfortherecommendations.Thelevelofev-idence that supports each recommenda-tion is listed after each recommendationusing the letters A, B, C, or E.These standards of care are revisedannually by the ADA multidisciplinaryProfessional Practice Committee, andnew evidence is incorporated. Membersof the Professional Practice Committeeandtheirdisclosedconﬂictsofinterestarelisted in the Introduction. Subsequently,as with all position statements, the stan-dards of care are reviewed and approvedby the Executive Committee of ADA’sBoard of Directors.
I. CLASSIFICATION ANDDIAGNOSIS
The classiﬁcation of diabetes includesfour clinical classes:
type 1 diabetes (results from
-cell de-struction, usually leading to absoluteinsulin deﬁciency)
type 2 diabetes (results from a progres-sive insulin secretory defect on thebackground of insulin resistance)
other speciﬁc types of diabetes due toother causes, e.g., genetic defects in
-cell function, genetic defects in insu-lin action, diseases of the exocrine pan-creas(suchascysticﬁbrosis),anddrug-or chemical-induced diabetes (such asin the treatment of AIDS or after organtransplantation)
gestational diabetes mellitus (GDM)(diabetes diagnosed during pregnancy)Some patients cannot be clearly classiﬁedas having type 1 or type 2 diabetes. Clin-ical presentation and disease progressionvary considerably in both types of diabe-tes. Occasionally, patients who otherwisehavetype2diabetesmaypresentwithke-toacidosis. Similarly, patients with type 1diabetes may have a late onset and slow(but relentless) progression despite hav-ing features of autoimmune disease. Suchdifﬁcultiesindiagnosismayoccurinchil-dren, adolescents, and adults. The truediagnosismaybecomemoreobviousovertime.
B. Diagnosis of diabetesRecommendations
For decades, the diagnosis of diabetes hasbeen based on plasma glucose (PG) crite-ria, either fasting PG (FPG) or 2-h 75-goralglucosetolerancetest(OGTT)values.In 1997, the ﬁrst Expert Committee onthe DiagnosisandClassiﬁcationofDiabe-tes Mellitus revised the diagnostic criteriausing the observed association between
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Originally approved 1988. Most recent review/revision October 2009.DOI: 10.2337/dc10-S011
ABI, ankle-brachial index; ACCORD, Action to Control Cardiovascular Risk in Diabetes; ADAG, A1C-Derived Average Glucose Trial; ADVANCE, Action in Diabetes and Vascular Disease: Pre-teraxandDiamicronModiﬁedReleaseControlledEvaluation;ACE,angiotensinconvertingenzyme;ARB,angiotensin receptor blocker; ACT-NOW, ACTos Now Study for the Prevention of Diabetes; BMI, bodymass index; CBG, capillary blood glucose; CFRD, cystic ﬁbrosis–related diabetes; CGM, continuousglucose monitoring; CHD, coronary heart disease; CHF, congestive heart failure; CCM, chronic caremodel;CKD,chronickidneydisease;CMS,CentersforMedicareandMedicaidServices;CSII,continuoussubcutaneous insulin infusion; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hyper-tension; DCCT, Diabetes Control and Complications Trial; DKA, diabetic ketoacidosis; DMMP, diabetesmedical management plan; DPN, distal symmetric polyneuropathy; DPP, Diabetes Prevention Program;DPS, Diabetes Prevention Study; DREAM, Diabetes Reduction Assessment with Ramipril and Rosiglita-zone Medication; DRS, Diabetic Retinopathy Study; DSME, diabetes self-management education; DSMT,diabetesself-managementtraining;eAG,estimatedaverageglucose;eGFR,estimatedglomerularﬁltrationrate; ECG, electrocardiogram; EDIC, Epidemiology of Diabetes Interventions and Complications; ERP,education recognition program; ESRD, end-stage renal disease; ETDRS, Early Treatment Diabetic Reti-nopathy Study; FDA, Food and Drug Administration; FPG, fasting plasma glucose; GDM, gestationaldiabetes mellitus; GFR, glomerular ﬁltration rate; HAPO, Hyperglycemia and Adverse Pregnancy Out-comes; ICU, intensive care unit; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; Look AHEAD, Action for Health in Diabetes; MDRD, Modiﬁcation of Diet in Renal Disease; MNT, medicalnutritiontherapy;NDEP,NationalDiabetesEducationProgram;NGSP,NationalGlycohemoglobinStan-dardization Program; NPDR, nonproliferative diabetic retinopathy; OGTT, oral glucose tolerance test;PAD,peripheralarterialdisease;PCOS,polycysticovariansyndrome;PDR,proliferativediabeticretinop-athy; PPG, postprandial plasma glucose; RAS, renin-angiotensin system; SMBG, self-monitoring of bloodglucose; STOP-NIDDM, Study to Prevent Non-Insulin Dependent Diabetes; SSI, sliding scale insulin;TZD,thiazolidinedione;UKPDS,U.K.ProspectiveDiabetesStudy;VADT,VeteransAffairsDiabetesTrial;XENDOS, XENical in the prevention of Diabetes in Obese Subjects.© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properlycited, the use is educational and not for proﬁt, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
P O S I T I O N S T A T E M E N T