Download - Diabetes Ada 2014 Cuidado Standar
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8/9/2019 Diabetes Ada 2014 Cuidado Standar
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S14 Diabetes Care Volume 37, Supplement 1, January 2014
Standards of Medical Care inAmerican Diabetes Association
Diabetesd2014
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Some patients cannot be clearlyclassi)ied as type 1 or type 2diabetic(
Clinical presentation and disease
pro*ression -ary considerably in
bot& types o) diabetes(
ccasionally, patients dia*nosed
.it& type 2 diabetes may present
.it& /etoacidosis( C&ildren .it&
type 1 diabetes typically present
.it& t&e &allmar/ symptoms o)polyuriapolydipsia and
occasionally .it& diabetic
/etoacidosis 'DA+( o.e-er,
di))iculties in dia*nosis may occur
in c&ildren, adolescents, and
adults, .it& t&e true dia*nosis
becomin* more ob-ious
o-er time(
ri*inally appro-ed1( %ost recentre-ie. re-isionctober 2013(
D!5 10(2337dc146
S014 2014 by t&e
American Diabetes
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Association( See &ttp5creati-ecommons(or*licensesby6 nc6nd3(0 )or details(
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care(diabetes8ournals(or* Position Statement S19
"able 1:ADA e-idence *radin* system )or Clinical Practice;ecommendations
uately po.ered,
includin*5c $-idence )rom a .ell6conducted trial at one or more institutions
c $-idence )rom a meta6analysis t&at incorporated >uality ratin*s in t&e analysis
B Supporti-e e-idence )rom .ell6conducted co&ort studiesc $-idence )rom a .ell6conducted prospecti-e co&ort study or re*istry
c $-idence )rom a .ell6conducted meta6analysis o) co&ort studies
Supporti-e e-idence )rom a .ell6conducted case6control study
C Supporti-e e-idence )rom poorly controlled or uncontrolled studies
c $-idence )rom randomi=ed clinical trials .it& one or more ma8or or t&reeor more minor met&odolo*ical )la.s t&at could in-alidate t&e results
c $-idence )rom obser-ational studies .it& &i*& potential )or bias 'suc& as case
series .it& comparison .it& &istorical controls+c $-idence )rom case series or case reports
Con)lictin* e-idence .it& t&e .ei*&t o) e-idence supportin* t&e recommendation
$ $?pert consensus or clinical e?perience
abnormal &emo*lobins s&ould be used( An
updated list is a-ailable at ...(n*sp(
or*inter)(asp( !n situations o) abnormal red
cell turno-er, suc& as pre*nancy, recent
blood loss or trans)usion, or some anemias,
only blood *lucose criteria s&ould be usedto dia*nose diabetes(
astin* and ".o6our Plasma
lucose
!n addition to t&e A1C test, t&e P and
26& P may also be used to dia*nose
diabetes( "&e current dia*nostic criteria
)or diabetes are summari=ed in "able 2(
"&e concordance bet.een t&e P and
26& P tests is ,100E( "&e concordance
bet.een A1C and eit&er *lucose6based
test is also imper)ect( #ational ealt&
and #utrition $?amination Sur-ey
'#A#$S+ data indicate t&at t&e A1C cutpoint o) FG(9E identi)ies one6t&ird )e.er
cases o) undia*nosed diabetes t&an a
)astin* *lucose cut point o) F12G m*dual clinical importance( "&e yper*lycemia and
Ad-erse Pre*nancy utcome 'AP+ study '43+, a lar*e6scale
'O29,000 pre*nant .omen+ multinational epidemiolo*ical study,
demonstrated t&at ris/ o) ad-erse maternal, )etal, and neonatal
outcomes continuously increased as a )unction o) maternal *lycemia
at 24K2 .ee/s, e-en .it&in ran*es pre-iously considered normal
)or pre*nancy( or most complications, t&ere .as no t&res&old )or
ris/( "&ese results &a-e led to care)ul reconsideration o) t&e
dia*nostic criteria )or D%( D% screenin* can be accomplis&ed
.it& eit&er o) t.o strate*ies5
1. @ne6step 26& 796* "" or
2. @".o6step approac& .it& a 16& 906* 'non)astin*+ screen
)ollo.ed by a 36& 1006* "" )or t&ose .&o screen positi-e
'"able G+
Di))erent dia*nostic criteria .ill identi)y di))erent ma*nitudes o)maternal &yper*lycemia and maternal)etal ris/(
!n t&e 2011 Standards o) Care '44+, ADA )or t&e )irst time
recommended t&at all pre*nant .omen not /no.n to &a-e prior
diabetes under*o a 796* "" at 24K2 .ee/s o) *estation based
on an !nternational Association o) Diabetes and Pre*nancy Study
roups '!ADPS+ consensus meetin* '49+( Dia*nostic cut points )or
t&e )astin*, 16&, and 26& P measurements .ere de)ined t&at
con-eyed an odds ratio )or ad-erse outcomes o) at least 1(79
compared .it& .omen .it& t&e mean *lucose le-els in t&e AP
study, a strate*y anticipated to si*ni)icantly increase t&e pre-alence
o) D% ')rom 9KGE to O19K20E+, primarily because only one
abnormal -alue, not t.o, is su))icient to ma/e t&e dia*nosis( ADA
reco*ni=ed t&at t&e anticipated increase in t&e incidence o) D%
dia*nosed by t&ese criteria .ould &a-e si*ni)icant impact on t&e
costs, medical in)rastructure capacity, and potential )or increased
@medicali=ation o) pre*nancies pre-iously cate*ori=ed as normal,
but
"able G:Screenin* )or anddia*nosis o)D%@ne6step'!ADPSconsensus+
Per)orm a 796*"", .it&plasma*lucosemeasurement)astin* and at1 and 2 &, at24K2 .ee/so) *estationin .omen notpre-iouslydia*nosed.it& o-ertdiabetes(
"&e ""s&ould beper)ormedin t&emornin*a)ter ano-erni*&t)ast o) atleast &(
"&e dia*nosiso) D% ismade .&enany o) t&e)ollo.in*plasma*lucose
-alues aree?ceeded5
c astin*5
F2 m*duent
insulin
in8ection
s or
noninsulint&erapies( $
3 &en
prescribi
n*S%B,
ensure
t&at
patients
recei-e
on*oin*
instructio
n and
re*ular
e-aluatio
n o)
S%B
tec&ni>ue and
S%B
results,
as .ell
as t&eir
ability to
use
S%B
data to
ad8ustt&erapy($
3&en
used
prop
erly,
conti
nuou
s
*luc
ose
moni
torin
*
'C
%+ in
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S22 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
con8unction .it& intensi-e insulin re*imens is a use)ul toolto lo.er A1C in selected adults 'a*ed F29 years+ .it& type1 diabetes(A
3Alt&ou*& t&e e-idence )or A1C lo.erin* is less stron* in
c&ildren, teens, and youn*er adults, C% may be &elp)ul in
t&ese *roups( Success correlates .it& ad&erence to on*oin*
use o) t&e de-ice( C
3 C% may be a supplemental tool to S%B in t&ose .it&
&ypo*lycemia una.areness andor )re>uent &ypo*lycemicepisodes( $
%a8or clinical trials o) insulin6treated patients t&at demonstrated t&e
bene)its o) intensi-e *lycemic control on diabetes complications &a-e
included S%B as part o) multi)actorial inter-entions, su**estin* t&at
S%B is a component o) e))ecti-e t&erapy( S%B allo.s patients to
e-aluate t&eir indi-idual response to t&erapy and assess .&et&er
*lycemic tar*ets are bein* ac&ie-ed( ;esults o) S%B can be use)ul
in pre-entin* &ypo*lycemia and ad8ustin* medications 'particularly
prandial insulin doses+, medical nutrition t&erapy '%#"+, and p&ysical
acti-ity( $-idence also supports a correlation bet.een S%B
)re>uency and lo.er A1C 'G2+(
S%B )re>uency and timin* s&ould be dictated by t&e patientHs
speci)ic needs and *oals( S%B is especially important )or patients
treated .it& insulin to monitor )or and pre-ent asymptomatic
&ypo*lycemia and &yper*lycemia( %ost patients .it& type 1 diabetes
or on intensi-e insulin re*imens '%D! or insulin pump t&erapy+ s&ould
consider S%B prior to meals and snac/s, occasionally
postprandially, at bedtime, prior to e?ercise, .&en t&ey suspect lo.
blood *lucose, a)ter treatin* lo. blood *lucose until t&ey are
normo*lycemic, and prior to critical tas/s suc& as dri-in*( or many
patients, t&is .ill re>uire testin* GK times daily, alt&ou*& indi-idualneeds may -ary( A database study o) almost 27,000 c&ildren and
adolescents .it& type 1 diabetes s&o.ed t&at, a)ter ad8ustment )or
multiple con)ounders, increased daily )re>uency o) S%B .as
si*ni)icantly associated .it& lo.er A1C '20(2E per additional test per
day, le-elin* o)) at )i-e tests per day+ and .it& )e.er acute
complications'G3+( or patientson nonintensi-einsulin re*imens,suc& as t&ose.it& type 2
diabetes on basalinsulin, .&en toprescribe S%Band t&e testin*)re>uency areunclear becauset&ere isinsu))iciente-idence )ortestin* in t&isco&ort(
Se-eral
randomi=ed trials&a-e called into
>uestion t&eclinical utility and
cost6e))ecti-eness
o) routine S%B
in noninsulin6treated patients
'G4KGG+(
A recent meta6
analysis
su**ested t&at
S%B reduced
A1C by 0(29E at
G mont&s 'G7+, buta Coc&rane
re-ie. concluded
t&at t&e o-erall
e))ect o) S%B in
suc& patients is
minimal up to G
mont&s a)ter
initiation and
subsides a)ter 12
mont&s 'G+( A /ey
consideration is
t&at S%B alone
does not lo.erblood *lucose
le-elO to be use)ul,
t&e in)ormation
must be inte*rated
into clinical and
sel)6mana*ement
plans(
S%B accuracy is
instrument and user
dependent 'G+, so
it is important to
e-aluate eac&patientHs monitorin*
tec&ni>ue, bot&
initially and at
re*ular inter-als
t&erea)ter( ptimal
use o) S%B
re>uires proper
re-ie. and
interpretation o) t&e
data, bot& by t&e
patient and
pro-ider( Amon*patients .&o
c&ec/ed t&eir
blood *lucose at
least once daily,
many reported
ta/in* no action
.&en results .ere
&i*& or lo. '70+( !n
one study o)
insulin6naR-e
patients .it&
suboptimal initial
*lycemic control,use o) structured
S%B 'a paper
tool to collect and
interpret 76point
S%B pro)iles
o-er 3 days at
least >uarterly+
reduced A1C by
0(3E more t&an an
acti-e control
*roup '71+(
Patients s&ould be
tau*&t &o. to useS%B data to
ad8ust )ood inta/e,
e?ercise, or
p&armacolo*ical
t&erapy to ac&ie-e
speci)ic *oals( "&e
on*oin* need )or
and )re>uency o)
S%B s&ould be
ree-aluated at
eac& routine -isit(
Continuouslucose %onitorin*
;eal6time C%
t&rou*& t&e
measurement o)
interstitial *lucose
'.&ic& correlates
.ell .it& plasma
*lucose+ is
a-ailable( "&ese
sensors re>uire
calibration .it&
S%B, and t&e
latter are stillre>uired )or ma/in*
acute treatment
decisions( C%
de-ices &a-e
alarms )or &ypo6
and &yper*lycemic
e?cursions( A 2G6
.ee/ randomi=ed
trial
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o) 322 type 1 diabetic patients s&o.ed t&at adults a*ed F29 years usin*
intensi-e insulin t&erapy and C% e?perienced a 0(9E reduction in A1C
')rom O7(G to 7(1E+ compared .it& usual intensi-e insulin t&erapy .it&
S%B '72+( Sensor use in t&ose ,29 years o) a*e 'c&ildren, teens, and
adults+ did not result in si*ni)icant A1C lo.erin*, and t&ere .as no
si*ni)icant di))erence in &ypo*lycemia in any *roup( "&e *reatest
predictor o) A1C lo.erin* )or all a*e6*roups .as )re>uency o) sensor use,
.&ic& .as lo.er in youn*er a*e6*roups( !n a smaller ;C" o) 12 adultsand c&ildren .it& baseline A1C ,7(0E, outcomes combinin* A1C and
&ypo*lycemia )a-ored t&e *roup usin* C%, su**estin* t&at C% is also
bene)icial )or indi-iduals .it& type 1 diabetes .&o &a-e already ac&ie-ed
e?cellent control '72+(
-erall, meta6analyses su**est t&at compared .it& S%B, C%
use is associated .it& A1C lo.erin* by O0(2GE '73+( "&e tec&nolo*y
may be particularly use)ul in t&ose .it& &ypo*lycemia una.areness
andor )re>uent &ypo*lycemic episodes, alt&ou*& studies &a-e not
s&o.n si*ni)icant reductions in se-ere &ypo*lycemia '73+( A C%
de-ice e>uipped .it& an automatic lo. *lucose suspend )eature .as
recently appro-ed
by t&e (S( ood
and Dru*
Administration
'DA+( "&e ASP!;$
trial o) 247 patients
s&o.ed t&at
sensor6au*mented
insulin pump
t&erapy .it& a lo.
*lucose suspendsi*ni)icantly
reduced nocturnal
&ypo*lycemia,
.it&out increasin*
A1C le-els )or
t&ose o-er 1G years
o) a*e '74+( "&ese
de-ices may o))er
t&e opportunity to
reduce se-ere
&ypo*lycemia )or
t&ose .it& a &istory
o) nocturnal
&ypo*lycemia(
C% )orms t&e
underpinnin* )or
t&e @arti)icial
pancreas or t&e
closed6loop
system( o.e-er,
be)ore C% is.idely adopted,
data must be
reported and
analy=ed usin* a
standard uni-ersal
template t&at is
predictable and
intuiti-e '79+(
b( A1C
Recommendations
3 Per)orm t&e
A1C test at
least t.o times
a year in
patients .&o
are meetin*
treatment
*oals 'and
.&o
&a-e stable*lycemiccontrol+( $
3 Per)orm t&e A1C
test >uarterly in
patients .&ose
t&erapy &as
c&an*ed
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care(diabetes8ournals(or* Position Statement S23
or .&o are not meetin* *lycemic *oals( $
3 se o) PC testin* )or A1C pro-ides t&e opportunity )or more
timely treatment c&an*es( $
A1C re)lects a-era*e *lycemia o-er se-eral mont&s 'G+ and &as
stron* predicti-e -alue )or diabetes complications '7G,77+( "&us,
A1C testin* s&ould be per)ormed routinely in all patients .it&
diabetes5 at initial assessment and as part o) continuin* care(
%easurement appro?imately e-ery 3 mont&s determines .&et&er
a patientHs *lycemic tar*ets &a-e been reac&ed and maintained(
"&e )re>uency o) A1C testin* s&ould be dependent on t&e clinical
situation, t&e treatment re*imen used, and t&e clinicianHs
8ud*ment( Some patients .it& stable *lycemia .ell .it&in tar*et
may do .ell .it& testin* only t.ice per year( nstable or &i*&ly
intensi-ely mana*ed patients 'e(*(, pre*nant type 1 diabetic
.omen+ may re>uire testin* more )re>uently t&an e-ery 3
mont&s(
A1C
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*oals 'suc& as ,G(9E+ )or selected indi-idual patients, i) t&is can be
ac&ie-ed .it&out si*ni)icant &ypo*lycemia or ot&er ad-erse e))ects
o) treatment( Appropriate patients mi*&t include t&ose .it& s&ort
duration o) diabetes, lon* li)e e?pectancy, and no
si*ni)icant CVD( C
3
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S24 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
control is associated .it& si*ni)icantly decreased rates o)
micro-ascular 'retinopat&y and nep&ropat&y+ and neuropat&ic
complications( ollo.6up o) t&e DCC" co&orts in t&e $pidemiolo*y o)
Diabetes !nter-entions and Complications '$D!C+ study '2,3+
demonstrated persistence o) t&ese micro-ascular bene)its in
pre-iously intensi-ely treated sub8ects, e-en t&ou*& t&eir *lycemiccontrol appro?imated t&at o) pre-ious standard arm sub8ects durin*
)ollo.6up(
umamoto and Prospecti-e Diabetes Study"&e umamoto '4+ and Prospecti-e Diabetes Study 'PDS+
'9,G+ con)irmed t&at intensi-e *lycemic control .as associated .it&
si*ni)icantly decreased rates o) micro-ascular and neuropat&ic
complications in type 2 diabetic patients( uired to ac&ie-e near6eu*lycemia
s&ould also be considered
.&en settin*
*lycemic tar*ets(
o.e-er, based on
p&ysician 8ud*ment
and patient
pre)erences, select
patients, especiallyt&ose .it& little
comorbidity and
lon* li)e
e?pectancy, may
bene)it )rom
adoptin* more
intensi-e *lycemic
tar*ets 'e(*(, A1C
tar*et ,G(9E+ as
lon* as si*ni)icant
&ypo*lycemia does
not become a
barrier(
Cardio-ascularDisease utcomesCVD is a more
common cause o)
deat& t&an
micro-ascular
complications in
populations .it&
diabetes( o.e-er, it
is less clearly
impacted by
&yper*lycemia le-els
or intensity o)*lycemic control( !n
t&e DCC", t&ere .as
a trend to.ard lo.er
ris/ o) CVD e-ents
.it& intensi-e
control( !n t&e 6year
post6DCC" )ollo.6up
o) t&e $D!C co&ort,
participants
pre-iously
randomi=ed to t&e
intensi-e arm &ad a
si*ni)icant 97Ereduction in t&e ris/
o) non)atal
myocardial in)arction
'%!+, stro/e, or CVD
deat& compared .it&
t&ose pre-iously in
t&e standard arm
'2+( "&e bene)it o)
intensi-e *lycemic
control in t&is type 1
diabetic co&ort &as
recently been s&o.n
to persist )or se-eraldecades '3+(
!n type 2 diabetes,
t&ere is e-idence
t&at more intensi-e
treatment o)
*lycemia in ne.ly
dia*nosed patients
may reduce lon*6
term CVD rates(
Durin* t&e PDS
trial, t&ere .as a1GE reduction in
CVD e-ents
'combined )atal or
non)atal %! and
sudden deat&+ in t&e
intensi-e *lycemic
control arm t&at did
not reac& statistical
si*ni)icance 'P 9
0(092+, and t&ere
.as no su**estion
o) bene)it on ot&er
CVD outcomes'e(*(, stro/e+(
o.e-er, a)ter 10
years o) )ollo.6up,
t&ose ori*inally
randomi=ed to
intensi-e *lycemic
control &ad
si*ni)icant lon*6term
reductions in %!
'19E .it&
sul)onylurea or
insulin as initial
p&armacot&erapy,33E .it& met)ormin
as initial
p&armacot&erapy+
and in all6cause
mortality '13E and
27E, respecti-ely+
'7+(
"&e Action to
Control
Cardio-ascular ;is/
in Diabetes
'ACC;D+, Action
in Diabetes and
Vascular Disease5
Pretera? and
Diamicron %odi)ied
;elease Controlled
$-aluation
'ADVA#C$+, and
t&e Veterans A))airs
Diabetes "rial
'VAD"+ studies
su**ested no
si*ni)icant reduction
in CVD outcomes
.it& intensi-e
*lycemic control in
participants .&o &ad
more ad-anced type
2 diabetes t&an
PDS participants(
All t&ree trials .ere
conducted in
participants .it&
more lon*6standin*
diabetes 'mean
duration K11 years+and
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eit&er /no.n CVD or multiple cardio-ascular ris/ )actors( Details o)
t&ese studies are re-ie.ed e?tensi-ely in an ADA position statement
'4+(
ACC;D
"&e ACC;D study participants &ad eit&er /no.n CVD or t.o or
more ma8or cardio-ascular ris/ )actors and .ere randomi=ed to
intensi-e *lycemic control '*oal A1C ,GE+ or standard *lycemic
control '*oal A1C 7KE+( "&e *lycemic control comparison .as
&alted early due to an increased mortality rate in t&e intensi-e
compared .it& t&e standard arm '1(41 -s( 1(14EyearO &a=ard ratio
L;M 1(22 L9E C! 1(01K 1(4GM+O .it& a similar increase in
cardio-ascular deat&s( !nitial analysis o) t&e ACC;D data
'e-aluatin* -ariables includin* .ei*&t *ain, use o) any speci)ic dru*
or dru* combination, and &ypo*lycemia+ did not identi)y a clear
e?planation )or t&e e?cess mortality in t&e intensi-e arm '1+( A
subse>uent analysis s&o.ed no increase in mortality in t&e intensi-e
arm participants .&o ac&ie-ed A1C le-els belo. 7E, nor in t&ose
.&o lo.ered t&eir A1C >uic/ly a)ter trial enrollment( "&ere .as no
A1C le-el at .&ic& intensi-e -ersus standard arm participants &ad
si*ni)icantly lo.er
mortality( "&e
&i*&est ris/ )or
mortality .as
obser-ed in
intensi-e arm
participants .it& t&e
&i*&est A1C le-els
'9+( Se-ere
&ypo*lycemia .as
si*ni)icantly moreli/ely in participants
randomi=ed to t&e
intensi-e *lycemic
control arm( nli/e
t&e DCC", .&ere
lo.er ac&ie-ed A1C
le-els .ere related
to si*ni)icantly
increased rates o)
se-ere
&ypo*lycemia, in
ACC;D e-ery
1E decline in A1C
)rom baseline to 4
mont&s into t&e
trial .as
associated .it& a
si*ni)icant
decrease in t&e
rate o) se-ere
&ypo*lycemia in
bot& arms '9+(
ADVA#C$
"&e primary
outcome o)
ADVA#C$ .as a
combination o)
micro-ascular
e-ents
'nep&ropat&y and
retinopat&y+ and
ma8or ad-erse
cardio-ascular
e-ents '%!, stro/e,
and cardio-ascular
deat&+( !ntensi-e
*lycemic control
'A1C ,G(9E, -s(
treatment to local
standards+
si*ni)icantly
reduced t&e primary
end point, primarilydue to a si*ni)icant
reduction in t&e
micro-ascular
outcome,
speci)ically
de-elopment o)
albuminuria '(300
m*24 &+, .it&
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care(diabetes8ournals(or* Position Statement S29
no si*ni)icant reduction in t&e macro-ascular outcome( "&ere .as
no di))erence in o-erall or cardio-ascular mortality bet.een t&e t.o
arms '+(
VAD"
"&e primary outcome o) t&e VAD" .as a composite o) CVD e-ents("&e trial randomi=ed type 2 diabetic participants .&o .ere
uncontrolled on insulin or on ma?imal dose oral a*ents 'median entry
A1C (4E+ to a strate*y o) intensi-e *lycemic control '*oal A1C ,
G(0E+ or standard *lycemic control, .it& a planned A1C separation
o) at least 1(9E( "&e cumulati-e primary outcome .as
nonsi*ni)icantly lo.er in t&e intensi-e arm '+( An ancillary study o)
t&e VAD" demonstrated t&at intensi-e *lycemic control si*ni)icantly
reduced t&e primary CVD outcome in indi-iduals .it& less
at&erosclerosis at baseline but not in persons .it& more e?tensi-e
baseline at&erosclerosis 'G+( A post &oc analysis s&o.ed t&at
mortality in t&e intensi-e -ersus standard *lycemic control arm .as
related to duration o) diabetes at study enrollment( "&ose .it&
diabetes duration less t&an 19 years &ad a mortality bene)it in t&eintensi-e arm, .&ile t&ose .it& duration o) 20 years or more &ad
&i*&er mortality in t&e intensi-e arm '7+(
ad-anced
at&erosclerosis,
and ad-anced
a*e)railty may
bene)it )rom less
a**ressi-e tar*ets(
Pro-iders s&ould be-i*ilant in
pre-entin* se-ere
&ypo*lycemia in
patients .it&
ad-anced disease
and s&ould not
a**ressi-ely
attempt to ac&ie-e
near6normal A1C
le-els in patients in
.&om suc& tar*ets
cannot be sa)ely
and reasonably
ac&ie-ed( Se-ere
or )re>uent
&ypo*lycemia is an
absolute indication
)or t&e modi)ication
o) treatment
re*imens, includin*
settin* &i*&er
*lycemic *oals(
%any )actors,
includin* patient
pre)erences, s&ould
be ta/en into
account .&en
de-elopin* a
patientHs
indi-iduali=ed *oals
'+ 'i*( 1+(
lycemic oals
;ecommended
*lycemic *oals )or
many nonpre*nant
adults are s&o.n
in "able ( "&e
recommendations
are based on
t&ose )or A1C
-alues, .it& blood
*lucose le-els t&at
appear to
correlate .it&
ac&ie-ement o) an
A1C o) ,7E( "&e
issue o) pre6
-ersus
postprandial
S%B tar*ets is
comple? '100+(
$le-ated
postc&allen*e '26
& ""+ *lucose
-alues &a-e been
associated .it&
increased
cardio-ascular ris/
independent o) P
in some
epidemiolo*icalstudies( !n diabetic
sub8ects, surro*ate
measures o)
-ascular pat&olo*y,
suc& as endot&elial
dys)unction, are
ne*ati-ely a))ected
by postprandial
&yper*lycemia '101+(
!t is clear t&at
postprandial
&yper*lycemia, li/e
preprandial
&yper*lycemia,
contributes to
ele-ated A1C le-els,
.it& its relati-e
contribution bein*
*reater at A1C le-els
t&at are closer to
7E( o.e-er,
outcome studies
&a-e clearly s&o.n
A1C to be t&e
primary predictor o)
complications, and
landmar/ *lycemic
control trials suc& as
t&e DCC" and
PDS relied
o-er.&elmin*ly on
preprandial S%B(
Additionally, an ;C"
in patients .it&
/no.n CVD )ound
no CVD bene)it o)
insulin re*imens
tar*etin*
postprandial *lucose
compared .it& t&ose
tar*etin* preprandial
*lucose '102+( A
reasonable
recommendation )or
postprandial testin*
and tar*ets is t&at )or
indi-iduals .&o &a-e
premeal *lucose
-alues .it&in tar*et
but &a-e A1C -alues
abo-e tar*et,
monitorin*
postprandial plasma
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*lucose 'PP+ 1K2 & a)ter t&e start o) t&e meal and treatment aimed at reducin*
"&e e-idence )or a cardio-ascular bene)it o)
intensi-e *lycemic control primarily rests on lon*6
term )ollo.6up o) study co&orts treated early in
t&e course o) type 1 and type 2 diabetes, and a
subset analyses o) ACC;D, ADVA#C$, and
VAD"( A *roup6le-el meta6analysis o) t&e latter
t&ree trials su**ests t&at *lucose lo.erin* &as a
modest 'E+ but statistically si*ni)icant reduction
in ma8or CVD outcomes, primarily non)atal %!,
.it& no si*ni)icant e))ect on mortality( o.e-er,
&etero*eneity o) t&e mortality e))ects across
studies .as noted( A prespeci)ied sub*roup
analysis su**ested t&at ma8or CVD outcome
reduction occurred in patients .it&out /no.n
CVD at baseline '; 0(4 L9E C! 0(74K0(4M+
'+(
Con-ersely,
t&e mortality
)indin*s in
ACC;D
and
sub*roup
analyses o)
t&e VAD"
su**est t&att&e potential
ris/s o)
intensi-e
*lycemic
control may
out.ei*& its
bene)its in
some
patients(
"&ose .it&
lon*
duration o)
diabetes,
/no.n
&istory o)
se-ere&ypo*lycemi
a,
i*ure 1:Approac& tomana*emento)&yper*lycemia( Depiction
o) t&eelements o)decisionma/in* usedto determineappropriatee))orts toac&ie-e*lycemic
tar*ets( C&aracteristicspredicaments to.ard t&e le)t
8usti)y more strin*ent e))ortsto lo.er A1C, .&ereas t&oseto.ard t&e ri*&t arecompatible .it& lessstrin*ent e))orts( &erepossible, suc& decisionss&ould be made incon8unction .it& t&e patient,re)lectin* &is or &er
pre)erences, needs, and-alues( "&is @scale is notdesi*ned to be applied ri*idlybut to be used as a broadconstruct to &elp *uideclinical decisions( Adapted.it& permission )rom !smail6Bei*i et al( '+(
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S2G Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
"able :Summary o) *lycemic recommendations )ormany nonpre*nantadults .it& diabetesA1C
Preprandial capillary plasma *lucose
Pea/ postprandial capillaryplasma *lucoseT c Ioalss&ould be indi-iduali=ed basedon5
c duration
o)
diabetesc
a*eli)e
e?pectanc
yc
comorbid
conditions
c /no.n CVD or ad-ancedmicro-ascularcomplications
c &ypo*lycemia una.arenessc indi-idual patient
considerationsc %ore orless strin*ent *lycemic
*oals
may be appropriate )or
indi-idual patients c Postprandial
*lucose may be tar*eted i) A1C
*oals are not met
despite reac&in*
preprandial *lucose
*oals
TPostprandial *lucose measurements s&ould be made 1K2 & a)ter t&ebe*innin* o) t&e meal, *enerally pea/ le-els in patients .it& diabetes(
1. se %D! in8ections '3K4in8ections perday o) basaland prandialinsulin+ or CS!!t&erapy(
2. %atc&prandialinsulin to
carbo&ydrate inta/e,premeal blood *lucose,and anticipated acti-ity(
3. or most patients 'especially.it& &ypo*lycemia+, useinsulin analo*s(
4. or patients .it& )re>uentnocturnal &ypo*lycemia andor&ypo*lycemia una.areness,use o) sensor6au*mented lo.*lucose suspend t&res&oldpump may be considered(
"&ere are
e?cellent
re-ie.s to *uide
t&e initiation and
mana*ement o)
insulin t&erapy to
ac&ie-e desired
PP -alues to ,10 m*d< may &elplo.er A1C(
lycemic *oals )or c&ildren are pro-idedin Section V!!!(A(1(a(
lycemic oals in Pre*nant omen
"&e *oals )or *lycemic control )or .omen .it&
D% are based on recommendations )rom t&e
i)t& !nternational or/s&op6Con)erence on
estational Diabetes %ellitus '103+ and &a-e
t&e )ollo.in* tar*ets )or maternal capillary
*lucose concentrations5
c Preprandial5 U9 m*d< '9(3mmol
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a 'G2 episodes per 100 patient6years o)
t&erapy+( Since t&e DCC", a number o) rapid6
actin* and lon*6actin* insulin analo*s &a-e
been de-eloped( "&ese analo*s are
associated .it& less &ypo*lycemia .it& e>ual
A1C lo.erin* in type 1 diabetes '109,10G+(
;ecommended t&erapy )or type 1diabetes consists o) t&e )ollo.in*components5
*lycemic *oals
'109,107,10+( Alt&ou*&
most studies o) %D!
-ersus pump t&erapy
&a-e been small and o)
s&ort duration, a
systematic re-ie. and
meta6analysis concluded
t&at t&ere .ere no
systematic di))erences in
A1C or se-ere&ypo*lycemia rates in
c&ildren and adults
bet.een t&e t.o )orms o)
intensi-e insulin t&erapy
'73+( ;ecently, a lar*e
randomi=ed trial in type 1
diabetic patients .it&
nocturnal &ypo*lycemia
reported t&at sensor6
au*mented insulin pump
t&erapy
.it& t&e
t&res&old6
suspend
)eature
reduced
nocturnal
&ypo*lycem
ia, .it&out
increasin*
*lycated&emo*lobin
-alues '74+(
-erall,
intensi-e
mana*eme
nt t&rou*&
pump
t&erapyC
% and
acti-e
patient)amil
y
participation
s&ould be
stron*ly
encoura*ed
'10K111+(
or selected
indi-iduals
.&o &a-e
masteredcarbo&ydrat
e countin*,
education on
t&e impact o)
protein and
)at on
*lycemic
e?cursions
can be
incorporated
into
diabetes
mana*eme
nt '112+(
Screenin*
Because o)t&eincreased
)re>uencyo) ot&erautoimmune diseasesin type 1diabetes,screenin*)or t&yroiddys)unction, -itamin
B12
de)iciency,and celiacdiseases&ould beconsideredbased onsi*ns andsymptoms(Periodicscreenin* in
asymptomaticindi-iduals&as beenrecommended, but t&ee))ecti-eness andoptimal)re>uencyare unclear(
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care(diabetes8ournals(or* Position Statement S27
i*ure 2:Anti&yper*lycemic t&erapy in type 2 diabetes5 *eneral recommendations( DPP646i, DPP64 in&ibitorO ?Hs, bone )racturesO !, *astrointestinalO
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on body .ei*&t, and &ypo*lycemia ris/( "&e position statement
rea))irms met)ormin as t&e pre)erred initial a*ent, barrin*
contraindication or intolerance, eit&er in addition to li)estyle
counselin* and support )or .ei*&t loss and e?ercise, or .&en
li)estyle e))orts alone &a-e not ac&ie-ed or maintained *lycemic
*oals( %et)ormin &as a lon*6standin* e-idence base )or e))icacy and
sa)ety, is ine?pensi-e, and may reduce ris/ o) cardio-ascular e-ents
'7+( &en met)ormin )ails to ac&ie-e or maintain *lycemic *oals,
anot&er a*ent
s&ould be added(
Alt&ou*& t&ere are
numerous trials
comparin* dual
t&erapy to
met)ormin alone,
)e. directly
compare dru*s as
add6on t&erapy(
Comparati-e
e))ecti-eness
meta6analyses
'114+ su**est t&at
o-erall, eac& ne.
class o) noninsulin
a*ents added to
initial t&erapy
lo.ers A1C around
0(K1(1E(
-
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S2 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
%any patients .it& type 2 diabetes e-entually re>uire and bene)it
)rom insulin t&erapy( "&e pro*ressi-e nature o) type 2 diabetes and
its t&erapies s&ould be re*ularly and ob8ecti-ely e?plained to patients(
Pro-iders s&ould a-oid usin* insulin as a t&reat or describin* it as a
)ailure or punis&ment( $>uippin* patients .it& an al*orit&m )or sel)6
titration o) insulin doses based on S%B results impro-es *lycemiccontrol in type 2 diabetic patients initiatin* insulin '119+( ;e)er to t&e
ADA6$ASD position statement )or more details on p&armacot&erapy
)or &yper*lycemia in type 2 diabetes '113+ 'i*( 2+(
$( %edical #utrition "&erapy
!eneral Recommendations
3 #utrition t&erapy is recommended )or all people .it& type 1
and type 2 diabetes as an e))ecti-e component
o) t&e o-erall treatment plan(A
3 !ndi-iduals .&o &a-e prediabetes or diabetes s&ould recei-e
indi-iduali=ed %#" as needed to ac&ie-e treatment *oals,
pre)erably pro-ided by a re*istered dietitian )amiliar .it& t&ecomponents o)
diabetes %#"(A
3 Because diabetes nutrition t&erapy can result in cost sa-in*s B
and impro-ed outcomes suc& as reduction in A1CA, nutrition
t&erapy s&ould be ade>uately reimbursed by insurance and ot&er
payers( $
$ner*y Balance, -er.ei*&t, and besity
3 or o-er.ei*&t or obese adults .it& type 2 diabetes or at ris/
)or diabetes, reducin* ener*y inta/e .&ile maintainin* a
&ealt&)ul eatin* pattern is recommended to promote
.ei*&t loss(A
3 %odest .ei*&t loss may pro-ide clinical bene)its 'impro-ed
*lycemia, blood pressure, andor lipids+ in some indi-iduals .it&
diabetes, especially t&ose early in t&e disease process( "o ac&ie-e
modest .ei*&t loss, intensi-e li)estyle inter-entions 'counselin*
about nutrition t&erapy, p&ysical acti-ity, and be&a-ior c&an*e+ .it&
on*oin* support are recommended(A
$atin* Patterns and %acronutrient
Distribution
3 $-idence su**ests t&at t&ere is not an ideal percenta*e o)
calories )rom
carbo&ydrate,
protein, and )at
)or all people
.it& diabetes BO
t&ere)ore,
macronutrient
distributions&ould be based
on indi-iduali=ed
assessment o)
current eatin*
patterns,
pre)erences, and
metabolic *oals(
$
3 A -ariety o)
eatin* patterns
'combinations
o) di))erent
)oods or )ood
*roups+ are
acceptable )or
t&e
mana*ement
o) diabetes(
Personal
pre)erence
'e(*(, tradition,
culture,
reli*ion, &ealt&
belie)s and
*oals,
economics+and metabolic
*oals s&ould
be considered
.&en
recommendin*
one eatin*
pattern o-er
anot&er( $
Carbo&ydrate Amountand Quality
3 %onitorin*
carbo&ydrateinta/e, .&et&er
by
carbo&ydrate
countin* or
e?perience6
based
estimation,
remains a /ey
strate*y in
ac&ie-in*
*lycemiccontrol( B
3 or *ood &ealt&,carbo&ydrate
inta/e )rom
-e*etables,
)ruits, .&ole
*rains, le*umes,
and dairy
products s&ould
be ad-ised o-er
inta/e )rom
ot&er
carbo&ydrate
sources,especially t&ose
t&at contain
added )ats,
su*ars,
or sodium( B
3 Substitutin*
lo.6*lycemic
load )oods )or
&i*&er6
*lycemic load
)oods may
modestlyimpro-e*lycemiccontrol( C
3 People .it&
diabetes s&ould
consume at
least t&e amount
o) )iber and
.&ole *rains
recommended
)or t&e *eneral
public( C
3 &ile
substitutin*
sucrose6
containin* )oods
)or isocaloric
amounts o)
ot&er
carbo&ydrates
may &a-e
similar blood
*lucose e))ects,
consumption
s&ould be
minimi=ed to
a-oid displacin*
nutrient6dense
)ood
c&oices(A
3 People .it&
diabetes and
t&ose at ris/ )or
diabetes s&ould
limit or a-oid
inta/e o) su*ar6
s.eetened
be-era*es
')rom anycaloric
s.eetener
includin* &i*&6
)ructose corn
syrup and
sucrose+ to
reduce ris/ )or
.ei*&t *ain and
.orsenin* o)
cardiometabolic
ris/ pro)ile( B
Dietary at Quantityand Quality
3 $-idence isinconclusi-e )oran idealamount o) total)at inta/e )orpeople .it&diabetesOt&ere)ore,*oals s&ouldbeindi-iduali=ed(Cat >ualityappears to be)ar moreimportant t&an>uantity( B
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care(diabetes8ournals(or* Position Statement S2
Alco&ol
3 !) adults .it& diabetes c&oose to drin/ alco&ol, t&ey s&ould be
ad-ised to do so in moderation 'one drin/ per day or less )or adult
.omen and t.o drin/s per day or less )or adult
men+( $
3 Alco&ol consumption may place people .it& diabetes at increased
ris/ )or delayed &ypo*lycemia, especially i) ta/in* insulin or insulin
secreta*o*ues( $ducation and a.areness re*ardin* t&e
reco*nition and mana*ement o) delayed &ypo*lycemia is
.arranted( C
Sodium
3 "&e recommendation )or t&e *eneral population to reduce sodium
to
,2,300 m*day is also appropriate )or people .it& diabetes( B
3 or indi-iduals .it& bot& diabetes and &ypertension, )urt&er
reduction in sodium inta/e s&ould be indi-iduali=ed( B
Primary Pre-ention o) "ype 2 Diabetes
3 Amon* indi-iduals at &i*& ris/ )or de-elopin* type 2 diabetes,
structured pro*rams t&at emp&asi=e li)estyle c&an*es t&at include
moderate .ei*&t loss '7E o) body .ei*&t+ and re*ular p&ysical
acti-ity '190 min.ee/+, .it& dietary strate*ies includin* reduced
calories and reduced inta/e o) dietary )at, can reduce t&e ris/ )or
de-elopin* diabetes and are t&ere)ore
recommended(A
3 !ndi-iduals at &i*& ris/ )or type 2 diabetes s&ould be encoura*ed
to ac&ie-e t&e (S( Department o) A*riculture 'SDA+
recommendation )or dietary )iber '14 * )iber1,000 /cal+ and )oods
containin* .&ole *rains 'one6&al) o) *rain inta/e+( B
"&e ADA recently released an updated position statement on
nutrition t&erapy )or adults li-in* .it& diabetes '11G+(
#utrition t&erapy is an inte*ral component o) diabetes pre-ention,
mana*ement, and sel)6mana*ement education( All indi-iduals .it&
diabetes s&ould recei-e indi-iduali=ed %#" pre)erably pro-ided by a
re*istered dietitian .&o is /no.led*eable and s/illed in pro-idin*
diabetes %#"( Compre&ensi-e *roup diabetes education pro*rams
includin* nutrition
t&erapy orindi-iduali=ededucationsessions &a-ereported A1Cdecreases o)
0(3K1E )or type 1diabetes '117K120+ and 0(9K2E)or type 2diabetes'9,121K137+(
!ndi-iduals .it&
type 1 diabetes
s&ould be o))ered
intensi-e insulin
t&erapy education
usin* t&e
carbo&ydrate6countin* meal
plannin* approac&
'117,11,120,124,1
3K140+O t&is
approac& &as been
s&o.n to impro-e
*lycemic control
'13,141+(
Consistent
carbo&ydrate inta/e
.it& respect to time
and amount can
result in impro-ed*lycemic control )or
indi-iduals usin*
)i?ed daily insulin
doses '142,143+( A
simple diabetes
meal plannin*
approac& suc& as
portion control or
&ealt&)ul )ood
c&oices may be
better suited )or
indi-iduals .it&
&ealt& literacy andnumeracy concerns
'129K127+(
ei*&t loss o) 2K
/* may pro-ide
clinical bene)its in
t&ose .it& type 2
diabetes, especially
early in t&e disease
process '144K14G+(
ei*&t loss studies
&a-e used a -ariety
o) ener*y6restrictedeatin* patterns,
.it& no clear
e-idence t&at one
eatin* pattern or
optimal
macronutrient
distribution .as
ideal( Alt&ou*&
se-eral studies
resulted in
impro-ements in
A1C at 1 year
'144,149,147K
14+, not all .ei*&t
loss inter-entions
led to 16year A1C
impro-ements
'12,190K194+(
"&e most
consistently
identi)ied c&an*es
in cardio-ascular
ris/ )actors .ere
an increase in Duality o)
li)e '213,21G,217+,
&ealt&y copin*
'21,21+, andlo.er costs
'220,221+( Better
outcomes .ere
reported )or DS%$
inter-entions t&at
.ere lon*er and
included )ollo.6up
support 'DS%S+
'207,222K224+, t&at
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care(diabetes8ournals(or* Position Statement S31
.ere culturally '229,22G+ and a*e appropriate '227,22+ and .ere
tailored to indi-idual needs and pre)erences, and t&at addressed
psyc&osocial issues and incorporated be&a-ioral strate*ies
'207,20,21,21,22K231+( Bot& indi-idual and *roup approac&es
&a-e been )ound e))ecti-e '232,233+( "&ere is *ro.in* e-idence )or
t&e role o) a community &ealt& .or/ers '234+ and peer '239K23+and lay leaders '240+ in deli-erin* DS%$ and DS%S as part o) t&e
DS%$S team '241+(
Diabetes education is associated .it& increased use o) primary and
pre-enti-e ser-ices '220,242,243+ and lo.er use o) acute, inpatient
&ospital ser-ices '220+( Patients .&o participate in diabetes
education are more li/ely to )ollo. best practice treatment
recommendations, particularly amon* t&e %edicare population, and
&a-e lo.er %edicare and commercial claim costs '221,242+(
"&e #ational Standards )or Diabetes Sel)6%ana*ement $ducation
and Support"&e #ational Standards )or Diabetes Sel)6%ana*ement $ducation and
Support are desi*ned to de)ine >uality DS%$ and DS%S and to assist
diabetes educators in a -ariety o) settin*s to pro-ide e-idence6based
education and sel)6mana*ement support '20G+( "&e standards are
re-ie.ed and updated e-ery 9 years by a tas/ )orce representin* /ey
or*ani=ations in-ol-ed in t&e )ield o) diabetes education and care(
Diabetes Sel)6%ana*ement $ducation and Support Pro-iders and
People it& Prediabetes"&e standards )or DS%$ and DS%S also apply to t&e education and
support o) people .it& prediabetes( Currently, t&ere are si*ni)icant
barriers to t&e pro-ision o) education and support to t&ose .it&
prediabetes( o.e-er, t&e strate*ies )or supportin* success)ul be&a-ior
c&an*e and t&e &ealt&y be&a-iors recommended )or people .it&prediabetes are lar*ely identical to t&ose )or people .it& diabetes( As
barriers to care are o-ercome, pro-iders o) DS%$ and DS%S, *i-en t&eir
trainin* and e?perience, are particularly .ell e>uipped to assist people
.it& prediabetes in de-elopin* and maintainin* be&a-iors t&at can
pre-ent or delay t&e onset o) diabetes '20G,244,249+(
;eimbursement
)or Diabetes Sel)6
%ana*ement
$ducation and
Support
DS%$, .&en
pro-ided by apro*ram t&at meets
national standards
)or DS%$ and is
reco*ni=ed by ADA
or ot&er appro-al
bodies, is
reimbursed as part
o) t&e %edicare
pro*ram as
o-erseen by t&e
Centers )or
%edicare and
%edicaid Ser-ices'C%S+( DS%$ is
also co-ered by
most &ealt&
insurance plans(
Alt&ou*& DS%S
&as been s&o.n to
be instrumental )or
impro-in*
outcomes, as
described in
@$-idence )or t&e
Bene)its o)
Diabetes Sel)6%ana*ement
$ducation and
Support, and can
be pro-ided in
)ormats suc& as
p&one calls and -ia
tele&ealt&, it
currently &as
limited
reimbursement as
)ace6to6)ace -isits
included as )ollo.6
up to DS%$(
( P&ysical Acti-ity
Recommendations
3 As is t&e case )or
all c&ildren,
c&ildren .it&
diabetes or
prediabetes
s&ould be
encoura*ed to
en*a*e in at
least
G0 min o)p&ysical acti-ityeac& day( B
3 Adults .it&
diabetes s&ould
be ad-ised to
per)orm at least
190 min.ee/ o)
moderate6
intensity aerobic
p&ysical acti-ity
'90K70E o)
ma?imum &eart
rate+, spread
o-er at least 3
days.ee/ .it&
no more t&an 2
consecuti-e days
.it&oute?ercise(A
3 !n t&e absence
o)
contraindication
s, adults .it&
type 2 diabetess&ould be
encoura*ed to
per)orm
resistance
trainin* at least
t.ice per .ee/(
A
$?ercise is an
important part o)
t&e diabetes
mana*ement plan(
;e*ular e?ercise&as been s&o.n to
impro-e blood
*lucose control,
reduce
cardio-ascular ris/
)actors, contribute
to .ei*&t loss, and
impro-e .ell6
bein*(
urt&ermore,
re*ular e?ercise
may pre-ent type 2
diabetes in &i*&6
ris/ indi-iduals
'23K29+(
Structured
e?ercise
inter-entions o) at
least .ee/sH
duration &a-e been
s&o.n to lo.er
A1C by an a-era*e
o) 0(GGE in people
.it& type 2
diabetes, e-en .it&
no si*ni)icant
c&an*e in B%!
'24G+( "&ere are
considerable data
)or t&e &ealt&
bene)its 'e(*(,
increased
cardio-ascular
)itness, muscle
stren*t&, impro-ed
insulin sensiti-ity,
etc(+ o) re*ular
p&ysical acti-ity )ort&ose .it& type 1
diabetes '247+(
i*&er le-els o)
e?ercise intensity
are associated .it&
*reater
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impro-ements in A1C and in )itness '24+( t&er bene)its include
slo.in* t&e decline in mobility amon* o-er.ei*&t patients .it&
diabetes '24+( A 8oint position statement o) ADA and t&e
American Colle*e o) Sports %edicine summari=es t&e e-idence
)or t&e bene)its o) e?ercise in people .it& type 2 diabetes '290+(
re>uency and "ype o) $?ercise
"&e (S( Department o) ealt& and uman Ser-icesH P&ysicalActi-ity uidelines )or Americans '291+ su**est t&at adults o-er a*e
1 years do 190 min.ee/ o) moderate6intensity, or 79 min.ee/ o)
-i*orous aerobic p&ysical acti-ity, or an e>ui-alent combination o)
t&e t.o( !n addition, t&e *uidelines su**est t&at adults also do
muscle6stren*t&enin* acti-ities t&at in-ol-e all ma8or muscle *roups
2 or more days .ee/( "&e *uidelines su**est t&at adults o-er a*e
G9 years, or t&ose .it& disabilities, )ollo. t&e adult *uidelines i)
possible or 'i) t&is is not possible+ be as p&ysically acti-e as t&ey are
able( Studies included in t&e meta6analysis o) e))ects o) e?ercise
inter-entions on *lycemic control '24G+ &ad a mean o) 3(4
sessions.ee/, .it&
a mean o) 4 min
session( "&e DPP
li)estyle
inter-ention, .&ic&
included 190
min.ee/ o)
moderate6intensity
e?ercise, &ad a
bene)icial e))ect on
*lycemia in t&ose.it& prediabetes(
"&ere)ore, it seems
reasonable to
recommend t&at
people .it&
diabetes )ollo. t&e
p&ysical acti-ity
*uidelines )or t&e
*eneral population(
Pro*ressi-e
resistance e?ercise
impro-es insulin
sensiti-ity in older
men .it& type 2
diabetes to t&e
same or e-en a
*reater e?tent as
aerobic e?ercise
'292+( Clinical trials
&a-e pro-idedstron* e-idence )or
t&e A1C lo.erin*
-alue o) resistance
trainin* in older
adults .it& type 2
diabetes
'293,294+, and )or
an additi-e bene)it
o) combined
aerobic and
resistance e?ercise
in adults .it& type 2
diabetes '299,29G+(
!n t&e absence o)
contraindications,
patients .it& type 2
diabetes s&ould be
encoura*ed to do
at least t.o .ee/ly
sessions o)resistance e?ercise
'e?ercise .it& )ree
.ei*&ts or .ei*&t
mac&ines+, .it&
eac& session
consistin* o) at
least one set o) )i-e
or
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S32 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
more di))erent resistance e?ercises in-ol-in* t&e lar*e muscle *roups
'290+(
Pre6e?ercise $-aluation o) t&e Diabetic Patient
As discussed more )ully in Section V!(A(9, t&e area o) screenin*
asymptomatic diabetic patients )or coronary artery disease 'CAD+
remains unclear( An ADA consensus statement on t&is issue
concluded t&at routine screenin* is not recommended '297+(
Pro-iders s&ould use clinical 8ud*ment in t&is area( Certainly, &i*&6
ris/ patients s&ould be encoura*ed to start .it& s&ort periods o) lo.6
intensity e?ercise and increase t&e intensity and duration slo.ly(
Pro-iders s&ould assess patients )or conditions t&at mi*&t
contraindicate certain types o) e?ercise or predispose to in8ury, suc&
as uncontrolled &ypertension, se-ere autonomic neuropat&y, se-ere
perip&eral neuropat&y or &istory o) )oot lesions, and unstable
proli)erati-e retinopat&y( "&e patientHs a*e and pre-ious p&ysical
acti-ity le-el s&ould be considered( or type 1 diabetic patients, t&e
pro-ider s&ould customi=e t&e e?ercise re*imen to t&e indi-idualHs
needs( "&ose .it& complications may re>uire a more t&orou*&
e-aluation '247+(
$?ercise in t&e Presence o)
#onoptimal lycemic Control
Hyerglycemia" &en people .it& type 1diabetes are depri-ed o)
insulin )or 12K4 & and are /etotic, e?ercise can .orsen
&yper*lycemia and /etosis '29+O t&ere)ore, -i*orous acti-ity
s&ould be a-oided in t&e presence o) /etosis( o.e-er, it is not
necessary to postpone e?ercise based simply on &yper*lycemia,
pro-ided t&e patient )eels .ell and urine andor blood /etones are
ne*ati-e(
Hyoglycemia" !n indi-iduals ta/in*insulin andor insulin secreta*o*ues,
p&ysical acti-ity can cause &ypo*lycemia i) medication dose or
carbo&ydrate consumption is not altered( or indi-iduals on t&eset&erapies, added carbo&ydrate s&ould be in*ested i) pre6e?ercise
*lucose le-els are ,100 m*d< '9(G mmol
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( Psyc&osocial Assessment and Care
Recommendations
3 !t is reasonable to include assessment o) t&e patientHs psyc&olo*ical
and social situation as an on*oin* part o) t&e
medical mana*ement o) diabetes( B
3 Psyc&osocial screenin* and )ollo.6up may include, but are not
limited to, attitudes about t&e illness, e?pectations )or medicalmana*ement and outcomes, a))ect mood, *eneral and
diabetes6related >uality o) li)e, resources ')inancial, social, and
emotional+, and
psyc&iatric &istory( $
3 ;outinely screen )or psyc&osocial problems suc& as
depression and diabetes6related distress, an?iety, eatin*
disorders, and co*niti-e impairment( B
$motional .ell6bein* is an important part o) diabetes care and sel)6
mana*ement( Psyc&olo*ical and social problems can impair t&e
indi-idualHs '2G3K2G9+ or )amilyHs ability '2GG+ to carry out diabetes
care tas/s and t&ere)ore compromise &ealt& status( "&ere are
opportunities )or t&e clinician to routinely assess psyc&osocial status
in a timely and
e))icient manner so
t&at re)erral )or
appropriate
ser-ices can be
accomplis&ed( A
systematic re-ie.
and meta6analysis
s&o.ed t&at
psyc&osocial
inter-entionsmodestly but
si*ni)icantly
impro-ed A1C
'standardi=ed
mean di))erence
20(2E+ and
mental &ealt&
outcomes(
o.e-er, t&ere .as
a limited
association
bet.een t&e e))ects
on A1C and mental
&ealt&, and no
inter-ention
c&aracteristics
predicted bene)it
on bot& outcomes
'2G7+(
Screenin*ey opportunities
)or routine
screenin* o)
psyc&osocial status
occur at dia*nosis,
durin* re*ularly
sc&eduled
mana*ement -isits,
durin*
&ospitali=ations,
.it& t&e disco-ery o)
complications, or
.&en problems .it&
*lucose control,
>uality o) li)e, or
sel)6mana*ement
are identi)ied(
Patients are li/ely to
e?&ibit psyc&olo*ical
-ulnerability at
dia*nosis and .&en
t&eir medical status
c&an*es, e(*(, end o)
t&e &oneymoon
period, .&en t&e
need )or intensi)iedtreatment is e-ident,
and .&en
complications are
disco-ered(
Depression a))ects
about 20K29E o)
people .it& diabetes
'2G+ and increases
t&e ris/ )or %! and
post6%! '2G+ and
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care(diabetes8ournals(or* Position Statement S33
all6cause mortality '270+( "&ere appears to be a bidirectional
relations&ip .it& bot& diabetes '271+ and metabolic syndrome '272+ and
depression(
Diabetes6related distress is distinct )rom clinical depression and is
-ery common '273K27G+ amon* people .it& diabetes and t&eir
)amily members '2GG+(
Pre-alence is reported as 1K49E, .it& an incidence o) 3K4E o-er 1
mont&s( i*& le-els o) distress are si*ni)icantly lin/ed to A1C, sel)6
e))icacy, dietary and e?ercise be&a-iors '21,274+, and medication ta/in*
'277+( t&er issues /no.n to impact sel)6mana*ement and &ealt&
outcomes include but are not limited to attitudes about t&e illness,
e?pectations )or medical mana*ement and outcomes, an?iety, *eneral
and diabetes6related >uality o) li)e, resources ')inancial, social, and
emotional+ '27+ and psyc&iatric &istory '27,20+( Screenin* tools are
a-ailable )or a number o) t&ese areas '22,21,22+(
;e)erral to %ental ealt& Specialist!ndications )or re)erral to a mental &ealt& specialist )amiliar .it&
diabetes mana*ement may include *ross disre*ard )or t&e
medical re*imen 'by sel) or ot&ers+ '23+, depression, possibility
o) sel)6&arm, debilitatin* an?iety 'alone or .it& depression+,
indications o) an eatin* disorder '24+, or co*niti-e )unctionin*
t&at si*ni)icantly impairs 8ud*ment( !t is pre)erable to incorporate
psyc&olo*ical assessment and treatment into routine care rat&er
t&an .aitin* )or a speci)ic problem or deterioration in metabolic
or psyc&olo*ical status '22,273+( !n t&e recent DA#2 study,
si*ni)icant diabetes6related distress .as reported by 44(GE o)
t&e participants, but only 23(7E reported t&at t&eir &ealt& care
team as/ed t&em &o. diabetes impacted t&eir li)e '273+(
Alt&ou*& t&e clinician may not )eel >uali)ied to treat psyc&olo*icalproblems '29+, usin* t&e patient6pro-ider relations&ip as a
)oundation can increase t&e li/eli&ood t&at t&e patient .ill accept
re)erral )or ot&er ser-ices( Collaborati-e care inter-entions and use
o) a team approac& &a-e demonstrated e))icacy in diabetes and
depression '2G,27+, and
inter-entions toen&ance sel)6mana*ement andaddress se-eredistress &a-e
demonstrated
e))icacy indiabetes6relateddistress '21+(
!( &en "reatmentoals Are #ot %et
Some people .it&
diabetes and t&eir
&ealt& care
pro-iders may not
ac&ie-e t&e desired
treatment *oals
'"able +(
;et&in/in* t&etreatment re*imen
may re>uire
assessment o)
barriers includin*
income, &ealt&
literacy, diabetes6
related distress,
depression, and
competin*
demands, includin*
t&ose related to
)amily
responsibilities anddynamics( t&er
strate*ies may
include culturally
appropriate and
en&anced DS%$
and DS%S,
comana*ement
.it& a diabetes
team, re)erral to a
medical social
.or/er )or
assistance .it&
insuranceco-era*e,
assessin*
medication6ta/in*
be&a-iors, or
c&an*e in
p&armacolo*ical
t&erapy( !nitiation o)
or increase in
S%B, use o)
C%, )re>uent
contact .it& t&e
patient, or re)erral
to a mental &ealt&pro)essional or
p&ysician .it&
special e?pertise in
diabetes may be
use)ul(
J( !ntercurrent!llness
"&e stress o)
illness, trauma,
andor sur*ery)re>uently
a**ra-ates
*lycemic control
and may
precipitate DA or
non/etotic
&yperosmolar
state, li)e6
t&reatenin*
conditions t&at
re>uire immediate
medical care to
pre-entcomplications and
deat&( Any
condition leadin*
to deterioration in
*lycemic control
necessitates more
)re>uent
monitorin* o) blood
*lucose and 'in
/etosis6prone
patients+ urine or
blood /etones( !)
accompanied by/etosis, -omitin*,
or alteration in
le-el o)
consciousness,
mar/ed
&yper*lycemia
re>uires temporary
ad8ustment o) t&e
treatment re*imen
and immediate
interaction .it& t&e
diabetes care
team( "&e patienttreated .it&
noninsulin
t&erapies or %#"
alone may
temporarily re>uire
insulin( Ade>uate
)luid and caloric
inta/e must be
assured( !n)ection
or de&ydration is
more li/ely to
necessitate
&ospitali=ation o)t&e person .it&
diabetes t&an t&e
person .it&out
diabetes(
"&e &ospitali=ed
patient s&ould be
treated by a
p&ysician .it&
e?pertise in
diabetes
mana*ement( or
)urt&er in)ormation
on mana*ement o)
patients
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.it& &yper*lycemia in t&e &ospital, see Section !W(A( or )urt&er
in)ormation on mana*ement o) DA or &yper*lycemic non/etotic
&yperosmolar state, re)er to t&e ADA statement on &yper*lycemic
crises '2+(
( ypo*lycemia
Recommendations
3 !ndi-iduals at ris/ )or &ypo*lycemia s&ould be as/ed about
symptomatic and asymptomatic &ypo*lycemia at
eac& encounter( C
3 lucose '19K20 *+ is t&e pre)erred treatment )or t&e conscious
indi-idual .it& &ypo*lycemia, alt&ou*& any )orm o)
carbo&ydrate t&at contains *lucose may be used( A)ter 19 min
o) treatment, i) S%B s&o.s continued &ypo*lycemia, t&e
treatment s&ould be repeated( nce S%B returns to normal,
t&e indi-idual s&ould consume a meal or snac/ to pre-ent
recurrence o) &ypo*lycemia( $
3 luca*on s&ould be prescribed )or all indi-iduals at si*ni)icant ris/
o) se-ere &ypo*lycemia, and care*i-ers or )amily members o)
t&ese indi-iduals s&ould be instructed on its administration(
luca*on
administration is
not limited to
&ealt& carepro)essionals($
3 ypo*lycemia
una.areness or
one or more
episodes o)
se-ere&ypo*lycemia
s&ould tri**er re6
e-aluation o) t&e
treatmentre*imen( $
3 !nsulin6treated
patients .it&
&ypo*lycemia
una.areness
or an episode
o) se-ere
&ypo*lycemia
s&ould be
ad-ised to
raise t&eir
*lycemic
tar*ets to
strictly a-oid
)urt&er
&ypo*lycemi
a )or at least
se-eral
.ee/s, to
partiallyre-erse
&ypo*lycemi
a
una.areness
and
reduce ris/ o))utureepisodes(A
3 n*oin*
assessment o)
co*niti-e
)unction is
su**ested .it&increased
-i*ilance )or
&ypo*lycemia by
t&e clinician,
patient, and
care*i-ers i) lo.
co*nition andor
declinin*
co*nition is
)ound( B
ypo*lycemia ist&e leadin*limitin* )actor int&e *lycemicmana*ement o)type 1 andinsulin6treatedtype 2 diabetes'2+( %ild&ypo*lycemiamay beincon-enient or)ri*&tenin* to
patients .it&diabetes( Se-ere
-
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S34 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
&ypo*lycemia can cause acute &arm to t&e person .it& diabetes or
ot&ers, especially i) it causes )alls, motor -e&icle accidents, or ot&er
in8ury( A lar*e co&ort study su**ested t&at amon* older adults .it&
type 2 diabetes, a &istory o) se-ere &ypo*lycemia .as associated
.it& *reater ris/ o) dementia '20+( Con-ersely, in a substudy o) t&e
ACC;D trial, co*niti-e impairment at baseline or decline inco*niti-e )unction durin* t&e trial .as si*ni)icantly associated .it&
subse>uent episodes o) se-ere &ypo*lycemia '21+( $-idence )rom
t&e DCC"$D!C trial, .&ic& in-ol-ed youn*er adults and adolescents
.it& type 1 diabetes, su**ested no association o) )re>uency o)
se-ere &ypo*lycemia .it& co*niti-e decline '22+, as discussed in
Section V!!!(A(1(a(
As described in Section V(b(2, se-ere &ypo*lycemia .as associated
.it& mortality in participants in bot& t&e standard and intensi-e
*lycemia arms o) t&e ACC;D trial, but t&e relations&ips .it&
ac&ie-ed A1C and treatment intensity .ere not strai*&t)or.ard( An
association o) se-ere &ypo*lycemia .it& mortality .as also )ound in
t&e ADVA#C$ trial '23+( An association o) sel)6reported se-ere
&ypo*lycemia .it& 96year mortality &as also been reported in clinical
practice '24+(
!n 2013, ADA and "&e $ndocrine Society publis&ed a consensus
report on t&e impact and treatment o) &ypo*lycemia on diabetic
patients( Se-ere &ypo*lycemia .as de)ined as an e-ent re>uirin*
assistance o) anot&er person( Noun* c&ildren .it& type 1 diabetes
and t&e elderly .ere noted as particularly -ulnerable due to t&eir
limited ability to reco*ni=e &ypo*lycemic symptoms and e))ecti-ely
communicate t&eir needs( "&e report recommended t&at s&ort6actin*
insulin slidin* scales, o)ten used in lon*6term care )acilities, s&ould
be a-oided and comple? re*imens simpli)ied( !ndi-iduali=ed patient
education, dietary inter-ention 'e(*(, bedtime snac/ to pre-ent
o-erni*&t &ypo*lycemia+, e?ercise mana*ement, medicationad8ustment, *lucose monitorin*, and routine clinical sur-eillance may
impro-e patient outcomes '29+(
ypo*lycemia
treatment re>uires
in*estion o) *lucose6
or carbo&ydrate6
containin* )oods(
"&e acute *lycemic
response correlatesbetter .it& t&e
*lucose content t&an
.it& t&e
carbo&ydrate content
o) t&e )ood( Pure
*lucose is t&e
pre)erred treatment,
but any )orm o)
carbo&ydrate t&at
contains *lucose .ill
raise blood *lucose(
Added )at may retard
and t&en prolon* té *lycemic
response( n*oin*
insulin acti-ity or
insulin
secreta*o*ues may
lead to recurrent
&ypo*lycemia unless
)urt&er )ood is
in*ested a)ter
reco-ery(
luca*on
"&ose in closecontact .it&, or
&a-in* custodial
care o), people .it&
&ypo*lycemia6
prone diabetes
')amily members,
roommates, sc&ool
personnel, c&ild
care pro-iders,
correctional
institution sta)), or
co.or/ers+ s&ould
be instructed onuse o) *luca*on
/its( An indi-idual
does not need to be
a &ealt& care
pro)essional to
sa)ely administer
*luca*on( A
*luca*on /it
re>uires a
prescription( Care
s&ould be ta/en to
ensure t&at
*luca*on /its arenot e?pired(
ypo*lycemia
Pre-entionypo*lycemia
pre-ention is a
critical component
o) diabetes
mana*ement(
S%B and, )or
some patients, C%
are /ey tools to
assess t&erapy anddetect incipient
&ypo*lycemia(
Patients s&ould
understand
situations t&at
increase t&eir ris/ o)
&ypo*lycemia, suc&
as .&en )astin* )or
tests or procedures,
durin* or a)ter
intense e?ercise,
and durin* sleep,
and t&at&ypo*lycemia may
increase t&e ris/ o)
&arm to sel) or
ot&ers, suc& as .it&
dri-in*( "eac&in*
people .it& diabetes
to balance insulin
use, carbo&ydrate
inta/e, and e?ercise
is a necessary but
not al.ays su))icient
strate*y )or
pre-ention( !n type 1diabetes and
se-erely insulin6
de)icient type 2
diabetes,
&ypo*lycemia
una.areness, or
&ypo*lycemia6
associated
autonomic )ailure,
can se-erely
compromise
strin*ent diabetes
control and >ualityo) li)e( "&e de)icient
counter6re*ulatory
&ormone release
and autonomic
responses in t&is
syndrome are bot&
ris/ )actors )or, and
caused by,
&ypo*lycemia( A
corollary to t&is
@-icious cycle is
t&at se-eral .ee/s
o) a-oidance o)&ypo*lycemia &as
been demonstrated
to impro-e counter6
re*ulation and
a.areness to some
e?tent in many
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patients '2G+( ence, patients .it& one or more episodes o) se-ere
&ypo*lycemia may bene)it )rom at least s&ort6term rela?ation o) *lycemic
tar*ets(
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care(diabetes8ournals(or* Position Statement S39
stomac& and &i*&er .it& t&ose t&at bypass portions o) t&e small intestine(
Additionally, intestinal bypass procedures may &a-e *lycemic e))ects t&at
are independent o) t&eir e))ects on .ei*&t, per&aps in-ol-in* t&e incretin
a?is(
"&ere is also e-idence )or diabetes remission )ollo.in* bariatric
sur*ery in persons .it& type 2 diabetes .&o are less se-erely obese(
ne randomi=ed trial compared ad8ustable *astric bandin* to @best
a-ailable medical and li)estyle t&erapy in sub8ects .it& type 2
diabetes and B%! 30K40 /*m2'302+( -erall, 73E o) sur*ically
treated patients ac&ie-ed @remission o) t&eir diabetes, compared
.it& 13E o) t&ose treated medically( "&e latter *roup lost only 1(7E
o) body .ei*&t, su**estin* t&at t&eir t&erapy .as not optimal( -erall
t&e trial &ad G0 sub8ects, and only 13 &ad a B%! under 39 /*m2,
ma/in* it di))icult to *enerali=e t&ese results .idely to diabetic
patients .&o are less se-erely obese or .it& lon*er duration o)
diabetes( !n a recent nonrandomi=ed study o) GG people .it& B%!
30K39 /*m2, E o) participants &ad remission o) t&eir type 2
diabetes up to G years a)ter sur*ery '303+(Disad-anta*esBariatric sur*ery is costly in t&e s&ort term and &as associated ris/s(
%orbidity and mortality rates directly related to t&e sur*ery &a-e been
reduced considerably in recent years, .it& 306day mortality rates no.
0(2E, similar to t&ose o) laparoscopic c&olecystectomy '304+( uire .ell
desi*ned clinical
trials, .it& optimal
medical and
li)estyle t&erapy,
and cardio-ascular
ris/ )actors as t&e
comparator(
%( !mmuni=ation
Recommendations
3 Annually pro-ide
an in)luen=a
-accine to all
diabetic patients
FG mont&s o)
a*e( C
3 Administer
pneumococcal
polysacc&aride
-accine to alldiabetic patients
F2 years o) a*e(
A one6time
re-accination is
recommended
)or indi-iduals (
G9 years o) a*e
.&o &a-e been
immuni=ed (9
years a*o(
t&er
indications )orrepeat
-accination
include
nep&rotic
syndrome,
c&ronic renal
disease, and
ot&er
immunocompro
mised states,
suc& as a)tertransplantation
( C3 Administer
&epatitis B
-accination to
un-accinated
adults .it&
diabetes .&o
are a*ed 1K9 years( C
3 Consider
administerin
* &epatitis B-accination
toun-accinated adults .it&diabetes.&o area*ed FG0years( C
!n)luen=a and
pneumonia are
common,
pre-entable
in)ectious diseases
associated .it&&i*& mortality and
morbidity in t&e
elderly and in
people .it& c&ronic
diseases( "&ou*&
t&ere are limited
studies reportin*
t&e morbidity and
mortality o)
in)luen=a and
pneumococcal
pneumonia
speci)ically inpeople .it&
diabetes,
obser-ational
studies o) patients
.it& a -ariety o)
c&ronic illnesses,
includin* diabetes,
s&o. t&at t&ese
conditions are
associated .it& an
increase in
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&ospitali=ations )or in)luen=a and its complications( People .it&
diabetes may be at increased ris/ o) t&e bacteremic )orm o)
pneumococcal in)ection and &a-e been reported to &a-e a &i*&
ris/ o) nosocomial bacteremia, .&ic& &as a mortality rate as
&i*& as 90E '311+(
Sa)e and e))ecti-e -accines t&at *reatly reduce t&e ris/ o) serious
complications )rom t&ese diseases are a-ailable '312,313+( !n a
case6control series, in)luen=a -accine .as s&o.n to reduce
diabetes6related &ospital admission by as muc& as 7E durin* )lu
epidemics '312+( "&ere is su))icient e-idence to support t&at people
.it& diabetes &a-e appropriate serolo*ic and clinical responses to
t&ese -accinations(
"&e CDC Ad-isory Committee on !mmuni=ation Practices
recommends in)luen=a and pneumococcal -accines )or all
indi-iduals .it& diabetes '&ttp5 ...(cdc(*o--accinesrecs+(
epatitis B Vaccine
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S3G Position Statement Diabetes Care Volume 37, Supplement 1, January 2014
diabetes a*ed 23 years and o-er compared .it& adults .it&out
diabetes( Seropre-alence o) antibody to BV core anti*en,
su**estin* past or current in)ection, is G0E &i*&er amon* adults
.it& diabetes t&an t&ose .it&out, and t&ere is some e-idence t&at
diabetes imparts a &i*&er BV case )atality rate( "&e a*e
di))erentiation in t&e recommendations stems )rom CDCeconomic models su**estin* t&at -accination o) adults .it&
diabetes .&o .ere a*ed 20K9 years .ould cost an estimated
F79,000 per >uality6ad8usted li)e6year sa-ed, .&ile cost per
>uality6ad8usted li)e6year sa-ed increased si*ni)icantly at &i*&er
a*es( !n addition to competin* causes o) mortality in older adults,
t&e immune response to t&e -accine declines .it& a*e '314+(
"&ese ne. recommendations re*ardin* BV -accinations ser-e as a
reminder to clinicians t&at c&ildren and adults .it& diabetes need a
number o) -accinations, bot& t&ose speci)ically indicated because o)
diabetes as .ell as t&ose recommended )or t&e *eneral population
'&ttp5...(cdc(*o- -accinesrecs+(
V!( P;$V$#"!# A#D %A#A$%$#" D!AB$"$SC%P
'e(*(, &ypertension and dyslipidemia+ are clear ris/ )actors )or CVD,
and diabetes itsel) con)ers independent ris/( #umerous studies &a-e
s&o.n t&e e))icacy o) controllin* indi-idual cardio-ascular ris/ )actorsin pre-entin* or slo.in* CVD in people .it& diabetes(
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3 !n pre*nant patients .it& diabetes and c&ronic &ypertension, blood
pressure tar*et *oals o) 110K12 G9K7 mm* are su**ested in
t&e interest o) lon*6term maternal &ealt& and minimi=in* impaired
)etal *ro.t&( AC$ in&ibitors and A;Bs are contraindicated durin*
pre*nancy( $
ypertension is a common comorbidity o) diabetes, a))ectin* t&e
ma8ority o) patients, .it& pre-alence dependin* on type o) diabetes,a*e, obesity, and et&nicity( ypertension is a ma8or ris/ )actor )or
bot& CVD and micro-ascular complications( !n type 1 diabetes,
&ypertension is o)ten t&e result o) underlyin* nep&ropat&y, .&ile in
type 2 diabetes it usually coe?ists .it& ot&er cardiometabolic ris/
)actors(
Screenin* and Dia*nosis
Blood pressure measurement s&ould be done by a trained indi-idual
and )ollo. t&e *uidelines establis&ed )or nondiabetic indi-iduals5
measurement in t&e seated position, .it& )eet on t&e )loor and arm
supported at &eart le-el, a)ter 9 min o) rest( Cu)) si=e s&ould be
appropriate )or t&e upper arm circum)erence( $le-ated -alues s&ould
be con)irmed on a
separate day(
ome blood
pressure sel)6
monitorin* and 246&
ambulatory blood
pressure monitorin*
may pro-ide
additional e-idence
o) @.&ite coat and
mas/ed
&ypertension and
ot&er discrepancies
bet.een o))ice and
@true blood
pressure( Studies in
nondiabetic
populations )ound
t&at &ome
measurements may
better correlate .it&
CVD ris/ t&an o))ice
measurements
'31,31+( o.e-er,
most o) t&e
e-idence o) bene)its
o) &ypertension
treatment in people
.it& diabetes is
based on o))ice
measurements(
"reatment oals
$pidemiolo*ical
analyses s&o. t&at
blood pressures (
11979 mm* are
associated .it&
increased
cardio-ascular
e-ent rates and
mortality in
indi-iduals .it&
diabetes '320K
322+ and t&at
SBP (120 mm*
predict lon*6term
end6sta*e renal
disease '$S;D+(
;andomi=ed clinical
trials &a-e
demonstrated t&e
bene)it 'reduction o)
CD e-ents,
stro/e, and
nep&ropat&y+ o)lo.erin* blood
pressure to ,140
mm* systolic
and ,0 mm*
diastolic in
indi-iduals .it&
diabetes
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care(diabetes8ournals(or* Position Statement S37
'320,323K329+( "&ere is limited e-idence )or t&e bene)its o) lo.er SBP
tar*ets(
"&e ACC;D trial e?amined .&et&er a lo.er SBP o) ,120
mm* pro-ides *reater cardio-ascular protection t&an an SBP
le-el o) 130K140 mm* in
patients .it& type 2 diabetes at &i*& ris/ )or CVD '32G+( "&e ; )or
t&e primary end point 'non)atal %!, non)atal stro/e, and CVD deat&+
in t&e intensi-e 'blood pressure 11G4 on 3(4 medications+ -ersus
standard *roup 'blood pressure 14370 on 2(1 medications+ .as 0(
'9E C! 0(73K1(0GO P 9 0(20+( ) t&e prespeci)ied secondary end
points, only stro/e and non)atal stro/e .ere statistically si*ni)icantly
reduced by intensi-e blood pressure treatment( "&e number needed
to treat to pre-ent one stro/e o-er t&e course o) 9 years .it&
intensi-e blood pressure mana*ement .as ( Serious ad-erse
e-ent rates 'includin* syncope and &yper/alemia+ .ere &i*&er .it&
intensi-e tar*ets '3(3E -s( 1(3EO P 9 0(001+( Albuminuria rates .ere
reduced .it& more intensi-e blood pressure *oals, but t&ere .ere no
di))erences in renal )unction nor in ot&er micro-ascularcomplications(
"&e ADVA#C$ trial 'treatment .it& an AC$ in&ibitor and a t&ia=ide6type
diuretic+ s&o.ed a reduced deat& rate but not in t&e composite
macro-ascular outcome( o.e-er, t&e ADVA#C$ trial &ad no speci)ied
tar*ets )or t&e randomi=ed comparison and t&e mean SBP in t&e
intensi-e *roup '139 mm*+ .as not as lo. as t&e mean SBP e-en in
t&e ACC;D standard6t&erapy *roup '327+( Post &oc analysis o)
ac&ie-ed blood pressure in se-eral &ypertension treatment trials &a-e
su**ested no bene)it o) lo.er ac&ie-ed SBP( As an e?ample, amon*
G,400 patients .it& diabetes and CAD enrolled in one trial, @ ti*&t control
'ac&ie-ed SBP ,130 mm*+ .as not associated .it& impro-ed
cardio-ascular outcomes compared .it& @usual care 'ac&ie-ed SBP
130K140 mm*+ '32+( Similar )indin*s emer*ed )rom an analysis o)
anot&er trial( "&ose .it& SBP ',119 mm*+ &ad increased rates o) CVD
e-ents, alt&ou*& t&ey &ad lo.er rates o) stro/e '32+(
bser-ational data, includin* t&at deri-ed )rom clinical trials,
may be
inappropriate )or
de)inin* blood
pressure tar*ets,
since sic/er
patients may &a-e
lo. blood
pressures or,con-ersely,
&ealt&ier or more
ad&erent patients
may ac&ie-e *oals
more readily( A
recent meta6
analysis o)
randomi=ed trials o)
adults .it& type 2
diabetes comparin*
prespeci)ied blood
pressure tar*ets
)ound no si*ni)icantreduction in
mortality or non)atal
%!( "&ere .as a
statistically
si*ni)icant 39E
relati-e reduction in
stro/e, but t&e
absolute ris/
reduction .as only
1E '330+(
%icro-ascular
complications .ere
not e?amined(Anot&er meta6
analysis t&at
included bot& trials
comparin* blood
pressure *oals and
trials comparin*
treatment strate*ies
concluded t&at a
systolic treatment
*oal o) 130K139
mm* .as
acceptable( it&
*oals ,130 mm*,t&ere .ere *reater
reductions in
stro/e, a 10E
reduction in
mortality, but no
reduction o) ot&er
CVD e-ents and
increased rates o)
serious ad-erse
e-ents( SBP ,130
mm* .as
associated .it&
reduced onset andpro*ression o)
albuminuria(
o.e-er, t&ere
.as &etero*eneity
in t&e measure,
rates o) more
ad-anced renal
disease outcomes
.ere not a))ected,
and t&ere .ere no
si*ni)icant c&an*es
in retinopat&y orneuropat&y '331+(
"&e clear body o)e-idence t&atSBP
(140 mm* is
&arm)ul su**ests
t&at clinicians
s&ould promptly
initiate and titrate
t&erapy in an
on*oin* )as&ion to
ac&ie-e and
maintain SBP ,140
mm* in -irtually
all patients(
Additionally,
patients .it& lon*
li)e e?pectancy 'in
.&om t&ere may
be renal bene)its
)rom lon*6term
stricter blood
pressure control+
or t&ose in .&om
stro/e ris/ is a
concern mi*&t, as
part o) s&ared
decision ma/in*,
appropriately &a-e
lo.er systolic
tar*ets suc& as ,
130 mm*( "&is is
especially true i) it
can be ac&ie-ed
.it& )e. dru*s and
.it&out side e))ects
o) t&erapy(
"reatmentStrate*ies
Alt&ou*& t&ere are
no .ell6controlled
studies o) diet and
e?ercise in t&e
treatment o)
ele-ated blood
pressure or
&ypertension in
indi-iduals .it&
diabetes, t&e
DAS study innondiabetic
indi-iduals &as
s&o.n
anti&ypertensi-e
e))ects similar to
p&armacolo*ical
monot&erapy(
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o) reducin* sodium inta/e ',1,900 m* day+ and e?cess body .ei*&tO
increasin* consumption o) )ruits, -e*etables 'K10 ser-in*s per day+, and
lo.6)at dairy products '2K3 ser-in*s per day+O a-oidin* e?cessi-e alco&ol
consumption 'no more t&an 2 ser-in*s per day in men and no more t&an
1 ser-in* per day in .omen+ '332+O and increasin* acti-ity le-els '320+(
"&ese nonp&armacolo*ical strate*ies may also positi-ely a))ect *lycemia
and lipid control and as a result s&ould be encoura*ed in t&ose .it& e-en
mildly ele-ated blood pressure( "&eir e))ects on cardio-ascular e-ents&a-e n