Standards of medical care in diabetes—2009

P O S I T I O N

S T A T E M E N T

Standards of Medical Care in Diabetes—2009
AMERICAN DIABETES ASSOCIATION

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iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, beaddressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factorsmay require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known orbelieved to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.I. CLASSIFICATION AND DIAGNOSIS A. Classification In 1997, ADA issued new diagnostic and classification criteria (4); in 2003, modifications were made regarding the diagnosis of impaired fasting glucose (5). The classification of diabetes includes four clinical classes:
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type 1 diabetes (results from -cell destruction, usually leading to absolute insulin deficiency) type 2diabetes (results from a progressive insulin secretory defect on the background of insulin resistance) other specific types of diabetes due to other causes, e.g., genetic defects in -cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced (such as in the treatment of AIDS or after organ transplantation) gestationaldiabetes mellitus (GDM) (diabetes diagnosed during pregnancy)

Some patients cannot be clearly classified as type 1 or type 2 diabetes. Clinical presentation and disease progression vary considerably in both types of diabetes. Occasionally, patients who otherwise have type 2 diabetes may present with ketoacidosis. Similarly, patients with type 1 may have a late onset and slow (but relentless)progression of disease despite having features of autoimmune disease. Such difficulties in diagnosis may occur in children, adolescents, and adults. The true diagnosis may become more obvious over time.

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The recommendations in this article are based on the evidence reviewed in the following publication:Standards of Care for Diabetes (Technical Review). Diabetes Care 17:1514 –1522, 1994. Originally approved 1988. Most recent review/revision October 2008. DOI: 10.2337/dc09-S013 © 2009 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 profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

B. Diagnosis of diabetes Current criteria for the diagnosis of diabetes in nonpregnant adults are shown in Table 2. Three ways to diagnose diabetes are recommended at the time of this statement, and each must be confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present. Although the 75-g oral glucose tolerance test (OGTT) is more sensitive...