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EXECUTIVE SUMMARY
Executive Summary: Standards of Medical Care
in Diabetesd2014
CURRENT CRITERIA FOR THE other cardiovascular disease (CVD) PREVENTION/DELAY OF TYPE 2
DIAGNOSIS OF DIABETES risk factors. B DIABETES
c A1C $6.5%. The test should be c Patients with impaired glucose
tolerance (IGT) A, impaired fasting
DOI: 10.2337/dc14-S005
© 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
S6 Executive Summary Diabetes Care Volume 37, Supplement 1, January 2014
frequent insulin injections or patients with a history of severe weight, comorbidities, hypoglycemia
noninsulin therapies. E hypoglycemia, limited life risk, and patient preferences. E
c When prescribing SMBG, ensure that expectancy, advanced microvascular c Due to the progressive nature of type
patients receive ongoing instruction or macrovascular complications, and 2 diabetes, insulin therapy is
and regular evaluation of SMBG extensive comorbid conditions and in eventually indicated for many
technique and SMBG results, as well those with long-standing diabetes in patients with type 2 diabetes. B
as their ability to use SMBG data to whom the general goal is difficult to
MEDICAL NUTRITION THERAPY
adjust therapy. E attain despite diabetes self-
c When used properly, continuous management education (DSME), General Recommendations
glucose monitoring (CGM) in appropriate glucose monitoring, and c Nutrition therapy is recommended
conjunction with intensive insulin effective doses of multiple glucose- for all people with type 1 and type 2
regimens is a useful tool to lower A1C lowering agents including insulin. B diabetes as an effective component
in selected adults (aged $25 years) of the overall treatment plan. A
preference (e.g., tradition, culture, containing long-chain n-3 fatty acids secretagogues. Education and
religion, health beliefs and goals, (EPA and DHA) (from fatty fish) and awareness regarding the recognition
economics) and metabolic goals n-3 linolenic acid (ALA) is recommended and management of delayed
should be considered when for individuals with diabetes because hypoglycemia is warranted. C
recommending one eating pattern of their beneficial effects on
Sodium
over another. E lipoproteins, prevention of heart
c The recommendation for the general
disease, and associations with positive
population to reduce sodium to
Carbohydrate Amount and Quality health outcomes in observational
,2,300 mg/day is also appropriate
c Monitoring carbohydrate intake, studies. B
for people with diabetes. B
whether by carbohydrate counting or c The amount of dietary saturated fat,
c For individuals with both diabetes
experience-based estimation, cholesterol, and trans fat
and hypertension, further reduction
remains a key strategy in achieving recommended for people with
in sodium intake should be
glycemic control. B diabetes is the same as that
c Because DSME and DSMS can result SMBG returns to normal, the IMMUNIZATION
in cost-savings and improved individual should consume a meal or c Annually provide an influenza vaccine
outcomes B, DSME and DSMS should snack to prevent recurrence of to all diabetic patients $6 months of
be adequately reimbursed by third- hypoglycemia. E age. C
party payers. E c Glucagon should be prescribed for all c Administer pneumococcal
individuals at significant risk of severe polysaccharide vaccine to all diabetic
PHYSICAL ACTIVITY
hypoglycemia, and caregivers or patients $2 years of age. A one-time
c As is the case for all children, children family members of these individuals revaccination is recommended for
with diabetes or prediabetes should should be instructed on its individuals .65 years of age who
be encouraged to engage in at least administration. Glucagon have been immunized .5 years ago.
60 min of physical activity each day. B administration is not limited to health Other indications for repeat
c Adults with diabetes should be care professionals. E vaccination include nephrotic
advised to perform at least 150 min/ c Hypoglycemia unawareness or one or syndrome, chronic renal disease, and
overweight; Dietary Approaches to baseline lipid levels, for diabetic c Aspirin should not be recommended
Stop Hypertension (DASH)-style patients: for CVD prevention for adults with
dietary pattern including reducing diabetes at low CVD risk (10-year CVD
sodium and increasing potassium c with overt CVD A risk ,5%, such as in men aged ,50
intake; moderation of alcohol intake; c without CVD who are over the age years and women aged ,60 years
and increased physical activity. B of 40 years and have one or more with no major additional CVD risk
c Pharmacological therapy for patients other CVD risk factors (family factors), since the potential adverse
with diabetes and hypertension history of CVD, hypertension, effects from bleeding likely offset the
should comprise a regimen that smoking, dyslipidemia, or potential benefits. C
includes either an ACE inhibitor or an albuminuria). A c In patients in these age-groups with
angiotensin receptor blocker (ARB). If multiple other risk factors (e.g.,
one class is not tolerated, the other c For lower-risk patients than the 10-year risk 5–10%), clinical judgment
should be substituted. C above (e.g., without overt CVD and is required. E
128-Hz tuning fork, pinprick confirmed on two additional or after puberty, consider obtaining a
sensation, ankle reflexes, or vibration specimens from different days. This fasting lipid profile soon after the
perception threshold). B should be obtained over a 6-month diagnosis (after glucose control has
c Provide general foot self-care interval following efforts to improve been established). E
education to all patients with glycemic control and normalize blood c For both age-groups, if lipids are
diabetes. B pressure for age. E abnormal, annual monitoring is
c A multidisciplinary approach is Hypertension reasonable. If LDL cholesterol values are
recommended for individuals with Screening within the accepted risk levels (,100
foot ulcers and high-risk feet, c Blood pressure should be measured mg/dL [2.6 mmol/L]), a lipid profile
especially those with a history of prior at each routine visit. Children found repeated every 5 years is reasonable. E
ulcer or amputation. B to have high-normal blood pressure Treatment
c Refer patients who smoke, have or hypertension should have blood c Initial therapy may consist of
LOPS and structural abnormalities,
c Consider referral to a conception, since drugs commonly c Annual monitoring for complications
gastroenterologist for evaluation used to treat diabetes and its of diabetes is recommended,
with possible endoscopy and biopsy complications may be beginning 5 years after the diagnosis
for confirmation of celiac disease in contraindicated or not recommended of CFRD. E
asymptomatic children with positive in pregnancy, including statins, ACE
antibodies. E inhibitors, ARBs, and most noninsulin DIABETES CARE IN THE HOSPITAL
c Children with biopsy-confirmed therapies. E c Diabetes discharge planning should
celiac disease should be placed on a c Since many pregnancies are start at hospital admission, and clear
gluten-free diet and have unplanned, consider the potential diabetes management instructions
consultation with a dietitian risks and benefits of medications that should be provided at discharge. E
experienced in managing both are contraindicated in pregnancy in c The sole use of sliding scale insulin in
diabetes and celiac disease. B all women of childbearing potential the inpatient hospital setting is
Hypothyroidism and counsel women using such discouraged. E