Introduction

and updated as needed. A list of recent sensus panel) of a scientic or medical position statements is included on p. S100 issue related to diabetes. Effective January of this supplement. 2010, consensus statements are renamed Systematic review. A balanced review consensus reports. The category will also and analysis of the literature on a scien- include task force, workgroup, and expert ADA position statement. An ofcial tic or medical topic related to diabetes. committee reports. Consensus reports point of view or belief of the ADA. PosiEffective January 2010, technical reviews will not have the Associations name intion statements are issued on scientic or are replaced with systematic reviews, for cluded in the title or subtitle and will inmedical issues related to diabetes. They which a priori search and inclusion/ clude a disclaimer in the introduction may be authored or unauthored and are exclusion criteria are developed and pub- stating that any recommendations are not published in ADA journals and other scilished. The systematic review provides a ADA position. A consensus report is typentic/medical publications as appropriscientic rationale for a position state- ically developed immediately following a ate. Position statements must be reviewed ment and undergoes critical peer review consensus conference at which presentaand approved by the Professional Practice before submission to the Professional tions are made on the issue under review. Committee and, subsequently, by the Practice Committee for approval. A list The statement represents the panels colExecutive Committee of the Board of Diof past technical reviews is included on lective analysis, evaluation, and opinion rectors. ADA position statements are page S97 of this supplement. at that point in time based in part on the typically based on a systematic review or other review of published literature. Consensus report. A comprehensive ex- conference proceedings. The need for a They are reviewed on an annual basis amination by a panel of experts (i.e., con- consensus report arises when clinicians or scientists desire guidance on a subject for which the evidence is contradictory or in complete. Once written by the panel, a DOI: 10.2337/dc10-S001. consensus report is not subject to subse 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for prot, and the work is not altered. See http://creativecommons. quent review or approval and does not represent ofcial Association opinion. A org/licenses/by-nc-nd/3.0/ for details.
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he American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years. These statements are published in one or more of the Associations professional journals. This supplement contains the latest update of ADAs major position statement, Standards of Medical Care in Diabetes, which contains all of the Associations key recommendations. In addition, contained herein are selected position statements on certain topics not adequately covered in the Standards. ADA hopes that this is a convenient and important resource for all health care professionals who care for people with diabetes. ADA Clinical Practice Recommendations consist of position statements that represent ofcial ADA opinion as denoted by formal review and approval by the Professional Practice Committee and the Executive Committee of the Board of Directors. Consensus reports and systematic reviews are not ofcial ADA recommendations; however, they are produced under the auspices of the Association by invited experts. These publications may be used by the Professional Practice Committee as source documents to update the Standards. ADA has adopted the following denitions for its clinically related reports.

Table 1ADA evidence-grading system for clinical practice recommendations Level of evidence A

Description Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including: Evidence from a well-conducted multicenter trial Evidence from a meta-analysis that incorporated quality ratings in the analysis Compelling nonexperimental evidence, i.e., the all or none rule developed by the Centre for Evidence-Based Medicine at Oxford Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including: Evidence from a well-conducted trial at one or more institutions Evidence from a meta-analysis that incorporated quality ratings in the analysis Supportive evidence from well-conducted cohort studies, including: Evidence from a well-conducted prospective cohort study or registry Evidence from a well-conducted meta-analysis of cohort studies Supportive evidence from a well-conducted case-control study Supportive evidence from poorly controlled or uncontrolled studies, including: Evidence from randomized clinical trials with one or more major or three or more minor methodological aws that could invalidate the results Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls) Evidence from case series or case reports Conicting evidence with the weight of evidence supporting the recommendation Expert consensus or clinical experience

Introduction list of recent consensus reports is included on p. S96 of this supplement. The Associations Professional Practice Committee is responsible for reviewing ADA systematic reviews and position statements, as well as for overseeing revisions of the latter as needed. Appointment to the Professional Practice Committee is based on excellence in clinical practice and/or research. The committee comprises physicians, diabetes educators, and registered dietitians who have expertise in a range of areas, including adult and pediatric endocrinology, epidemiology, and public health, lipid research, hypertension, and preconception and pregnancy care. All members of the Professional Practice Committee are required to disclose potential conicts of interest (listed below). Grading of scientic evidence. There has been considerable evolution in the evaluation of scientic evidence and in the development of evidence-based guidelines since the ADA rst began publishing practice guidelines. Accordingly, we developed a classication system to grade the quality of scientic evidence supporting ADA recommendations for all new and revised ADA position statements. Recommendations are assigned ratings of A, B, or C, depending on the quality of evidence (Table 1). Expert opinion (E) is a separate category for recommendations in which there is as yet no evidence from clinical trials, in which clinical trials may be impractical, or in which there is conicting evidence. Recommendations with an A rating are based on large well-designed clinical trials or well-done meta-analyses. Generally, these recommendations have the best chance of improving outcomes when applied to the population to which they are appropriate. Recommendations with lower levels of evidence may be equally important but are not as well supported. The level of evidence supporting a given recommendation is noted either as a heading for a group of recommendations or in parentheses after a given recommendation. Of course, evidence is only one component of clinical decision-making. Clinicians care for patients, not populations; guidelines must always be interpreted with the needs of the individual patient in mind. Individual circumstances, such as comorbid and coexisting diseases, age, education, disability, and, above all, patients values and preferences, must also be considered and may lead to different treatment targets and strategies. Also, conventional evidence hierarchies, such as the one adapted by the ADA, may miss some nuances that are important in diabetes care. For example, while there is excellent evidence from clinical trials supporting the importance of achieving glycemic control, the optimal way to achieve this result is less clear. It is difcult to assess each component of such a complex intervention. ADA will continue to improve and update the Clinical Practice Recommendations to ensure that clinicians, health plans, and policymakers can continue to rely on them as the most authoritative and current guidelines for diabetes care. Our Clinical Practice Recommendations are also available on the Associations website at www.diabetes.org/diabetescare. DUALITIES OF INTEREST Professional Practice Committee Members John E. Anderson, MD, is on the speakers bureau for Amylin/Eli Lilly*, GlaxoSmithKline*, Daichi/Sankyo, and Novo Nordisk. Joan Bardsley, RN, MBA, CDE, has received research funding from Novo Nordisk*, has received honoraria from Novo Nordisk* and GlaxoSmithKline*, and owns stock in Pzer* and Amylin. John B. Buse, MD, PhD, has conducted research and/or consulted under contract between the University of North Carolina and Amylin*, Bayhill Therapeutics, Becton Dickinson*, BristolMyers Squibb*, DexCom*, Eli Lilly*, GI Dynamics, GlaxoSmithKline*, Halozyme*, Hoffman-LaRoche*, Interkrin*, Johnson & Johnson*, LipoScience*, Mannkind*, Medtronic*, Merck*, Novartis*, Novo Nordisk*, Osiris*, Pzer*, sano-aventis*, Tolerex*, Transition Therapeutics*, and Wyeth; and owns stock in Insulet*. Martha Funnell, MS, RN, CDE, has been on the advisory board for Novo Nordisk, Eli Lilly, HDI Diagnostics, Intuity Medical, GlaxoSmithKline, and Mannkind and has been a consultant for sano-aventis. Curt D. Furberg, MD, PhD, has been a member of the data safety monitoring committee for Wyeth. Sheila Y. Garris, MD, FACP, has been a speaker for Takeda, Osient, GlaxoSmithKline, and Novartis and has been a speaker and consultant for Merck, Forrest*, and Daiichi Sankyo. Silvio E. Inzucchi, MD, has been a consultant/advisor for Takeda, Merck*, Amylin, Daiichi Sankyo, and Medtronic; has accepted honoraria from Novo Nordisk; and has received research funding from Eli Lilly*; Takeda, Merck, Amylin, and Boehringer Ingelheim have provided educational grants* to Yale University for work conducted by him. Wahida Karmally, DrPH, RD, CDE, CLS, reports no duality of interest. Antoinette Moran, MD, has been on the advisory committee for Bayer. Peter D. Reaven, MD, has received research support from Takeda* and Amylin*, is a member of the speakers bureau for Merck, and is on the advisory panel of and is a board member for Bristol-Myers Squibb. Guillermo Umpierrez, MD, has received research funding from sano-aventis*, Novo Nordisk*, Takeda*, and Eli Lilly*. Craig Williams, PharmD, has received research funding from Merck* and speaker fees from Merck/Schering Plough and has a relative employed by Pzer. David F. Williamson, PhD, reports no duality of interest. Peter Wilson, MD, has received research funding from GlaxoSmithKline*. Carol H. Wysham, MD, has been a speaker for Eli Lilly*, Merck, Novo Nordisk, and sano-aventis and a consultant and speaker for Amylin Pharmaceuticals*. American Diabetes Association Staff M. Sue Kirkman, MD, and Stephanie A. Dunbar, MPH, RD, report no duality of interest.

*Amount $10,000/year.

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