- Click here for explanation of classification scheme.

Standards of diabetes care seek to provide physicians and other health care professionals who treat people with diabetes with a means to:

1. Set treatment goals
2. Assess the quality of diabetes treatment provided
3. Identify areas where more attention or self-management training is needed
4. Define timely and necessary referral patterns to appropriate specialists

Patients with diabetes with a means to:

1. Assess the quality of medical care they receive
2. Develop expectations for their role in the medical treatment
3. Compare their treatment outcomes with standard goals

 

None specifically mentioned.

None specifically mentioned.

Recruitment: 

Methods of study inclusion not detailed in this article.

Design

Consensus Report

Blinding Used (if applicable):

Not applicable.

Intervention (if applicable):

A grading system developed by the American Diabetes Association and modeled after existing methods was utilized to clarify and codify the evidence that forms the basis for the recommendations.

Statistical Analysis: 

Statistical analysis not completed in this report.

Timing of Measurements

Not applicable.

Dependent Variables

Not applicable.

Independent Variables

Not applicable.

Control Variables 

Initial N:  Number of studies included not detailed in this consensus report, 91 references cited

Attrition (Final N):  Not applicable.

Age:  Not mentioned

Ethnicity:  Not mentioned

Other relevant demographics:

Anthropometry:

Location:  Worldwide studies

Glycemic control for people with diabetes

	Normal mg/dl	Goal mg/dl	Action needed mg/dl
Whole Blood Average Preprandial	<100	80-120	<80/>140
Average Bedtime	<110	100-140	<100/>160
Plasma values Average Preprandial	<110	90-130	<90/>150
Average Bedtime	<120	110-150	<110/>180
HbA1c (%)	<6	<7	>8

Achieving blood glucose goals in patients requires comprehensive education in self-management, and for most, intensive treatment programs. Such programs include the following components according to individual patient need:

1. Appropriate frequency of self-monitoring of blood glucose (SMBG)
2. Medical nutrition therapy (MNT)
3. Regular exercise
4. Physiologically based insulin regimens
5. Less-complex insulin regimens or oral glucose-lowering agents in some type 2 patients
6. Instruction in the prevention and treatment of hypoglycemia and other acute and chronic complications
7. Continuing education and reinforcement
8. Period assessment of treatment goals

Type 1 Diabetes Mellitus

The desired outcome of glycemic control is to achieve maximum prevention of complications with due regard for patient safety. To achieve these goals with intensive management, the following may be necessary:

1. Frequent SMBG (3-4 times/day)
2. Medical nutrition therapy
3. Education in self-management and problem solving
4. Possible hospitalization for initiation of therapy.

Type 2 Diabetes Mellitus

Improved blood glucose control reduces the risk of developing retinopathy and nephropathy and possibly reduces neuropathy. Overall microvascular complications rate was decreased by 25% in patients receiving intensive therapy versus conventional therapy (UKPDS study).

1. Daily SMBG important for those on insulin or sulfonylureas to monitor for and prevent hypoglycemia.
2. The role of SMBG in stable diet-treated patients is not known.
3. Treatment should emphasize diabetes management as a multiple risk factor approach including MNT, exercise, weight reduction if indicated, use of oral glucose-lowering agents and/or insulin.

All Types of Diabetes

Initial Visit

Medical history, physical exam, laboratory evaluation and management plan.

Management plan:

1. Short & long-term goals
2. Medications
3. Individualized nutrition recommendations and instructions preferably by RD familiar with components of diabetes MNT
4. Recommendations for lifestyle changes (exercise, smoking cessation)
5. Patient/family education for self-management
6. Monitoring instructions: SMBG, urine ketones, and use of a record system.
7. Annual comprehensive dilated eye and visual exam by an ophthalmologist or optometrist for all patients >10 years who have had diabetes for 3-5 yr, all patients after 30 yrs of age or if symptomatic
8. Consultation for podiatry services as indicated
9. Consultation for specialized services as indicated
10. Agreement on continuing support, follow-up, return appointments
11. Instructions on when and how to contact the physician or other health care team members when patient unable to solve problems

Continuing Care

Visit frequency

1. Patients beginning treatment with MNT or oral glucose-lowering agents may need to be contacted as often as weekly until reasonable glucose control is achieved and they are competent to conduct the treatment program.
2. Patients should generally be seen at least quarterly until achievement of treatment goals.
3. Once patients have met treatment goals, semiannual visits are recommended.

Evaluation of management plan

The management plan should be reviewed at each regular visit to determine progress in meeting goals and to identify problems:

1. Control of blood glucose levels
2. Assessment of complications
3. Control of blood pressure
4. Control of dyslipidemia
5. Nutrition assessment
6. Frequency of hypoglycemia
7. Adherence to all aspects of self-care
8. Evaluation of exercise regimen
9. Follow-up of referrals
10. Psychosocial adjustment
11. Knowledge of diabetes and self-management skills reassessed at least annually.

Children and Adolescents

Diabetes care for children <18 yr of age should be provided by a team that can deal with the special medical, educational, nutritional and behavioral issues

Glycemic goals may need to be modified for children <6 to 7 yr of age since children are unable to recognize the symptoms of hypoglycemia. Sick day management rules need to be taught to prevent severe hyperglycemia and DKA requiring hospitalization.

A nutritional assessment should be performed at diagnosis or at least annually thereafter by an individual experienced with the nutrition needs of the growing child and behavioral issues that have an impact on adolescent diets.

Diabetes is a chronic illness that requires continuing medical care and education to prevent acute complications and to reduce the risk of long-term complications. People with diabetes should receive their treatment and care from a physician-coordinated team. Such teams include, but are not limited to health care professionals with expertise and a special interest in diabetes:

• Physicians
• Nurses
• Dietitians
• Mental health professionals

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Medical Nutrition Therapy is an important component of the initial and ongoing treatment for individuals with diabetes mellitus.

MNT should be initiated when the diagnosis of diabetes is made with weekly follow-up visits with the team including the RD until blood glucose goals are met.

For continuous care, semi-annual visits with the team should include a nutritional assessment and appropriate nutrition counseling by an RD. Counseling would include an evaluation of knowledge and skills in self-management and adjustment of diet and physical activity to meet these blood glucose goals and to prevent acute and chronic complications of poor diabetes control.