ada std of dm care 2009 exe summary

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Executive Summary: Standards of MedicalCare in Diabetes2009

Current Criteria for the Diagnosis ofDiabetes Fasting plasma glucose (FPG) 126

mg/dl (7.0 mmol/l). Fasting is definedas no caloric intake for at least 8 h

Symptoms of hyperglycemia and a ca-sual (random) plasma glucose 200mg/dl (11.1 mmol/l). Casual (random)is defined as any time of day withoutregard to time since last meal. The clas-sic symptoms of hyperglycemia includepolyuria, polydipsia, and unexplainedweight loss.

2-h plasma glucose 200 mg/dl (11.1mmol/l) during an oral glucose toler-ance test (OGTT). The test should beperformed as described by the WorldHealth Organization, using a glucoseload containing the equivalent of 75 ganhydrous glucose dissolved in water.

Testing for Pre-Diabetes andDiabetes in Asymptomatic Patients Testing to detect pre-diabetes and type

2 diabetes in asymptomatic peopleshould be considered in adults of anyage who are overweight or obese (BMI25 kg/m2) and who have one or moreadditional risk factors for diabetes). Inthose without these risk factors, testingshould begin at age 45 years. (B)

If tests arenormal, repeattesting shouldbe carried out at least at 3-year inter-vals. (E)

To test for pre-diabetes or diabetes, anFPG test or 2-h OGTT (75-g glucoseload) or both are appropriate. (B)

An OGTT may be considered in pa-tients with impaired fasting glucose(IFG) to better define the risk of diabe-tes. (E)

In those identified with pre-diabetes,identify and, if appropriate, treat othercardiovascular disease (CVD) risk fac-tors. (B)

Testing for Type 2 Diabetes inChildren Test children who are overweight (BMI85th percentile for age and sex,weight for height 85th percentile, orweight120% of ideal for height) andhave any two of the following risk fac-tors: Family history of type 2 diabetes in

first- or second-degree relative Race/ethnicity of Native American,

African American, Latino, AsianAmerican, or Pacific Islander

Signs of insulin resistance or condi-tions associated with insulin resis-t a n c e ( a c a n t h o s i s n i g r i c a n s ,hypertension, dyslipidemia, polycys-tic ovary syndrome, or small-for-gestational-age birth weight)

Maternal history of diabetes or gesta-tional diabetes mellitus (GDM) dur-ing the childs gestation (E)

Testing should begin at age 10 yearsor at onset of puberty, if puberty oc-curs at a younger age, and be re-peated every 3 years. (E)

FPG is the preferred test. (E)

Detection and Diagnosis of GDM Screen for GDM using risk factor anal-

ysis and, if appropriate, use of anOGTT. (C)

Women with GDM should be screenedfor diabetes 612 weeks postpartumand should be followed up with subse-quent screening for the development ofdiabetes or pre-diabetes. (E)

Prevention/Delay of Type 2 Diabetes

Patients with impaired glucose toler-ance (A) or IFG (E) should be referredto an effective ongoing support pro-gram for weight loss of 510% of bodyweight and increasing physical activityto at least 150 min per week of moder-ate activity such as walking.

Follow-up counseling appears to be im-portant for success. (B)

Based on potential cost savings of diabe-tes prevention, such counseling shouldbe covered by third-party payors. (E)

Glucose Monitoring Self-monitoring of blood glucose

(SMBG) should be carried out three ormore times daily for patients using mul-tiple insulin injections or insulin pumptherapy. (A)

For patients using less frequent insulin

injections, noninsulin therapies, ormedical nutrition therapy (MNT) andphysical activity alone, SMBG may beuseful as a guide to the success of ther-apy. (E)

To achieve postprandial glucose tar-gets, postprandialSMBG may be appro-priate. (E)

When prescribing SMBG, ensure thatpatients receive initial instruction in,and routine follow-up evaluation of,SMBG technique and their ability to usedata to adjust therapy. (E)

Continuous glucose monitoring (CGM)in conjunction with intensive insulinregimens can be a useful tool to lower

A1C in selected adults (aged 25years) with type 1 diabetes (A).

Although evidence for A1C lowering isless strong in children, teens, andyounger adults, CGM may be helpful inthese groups. Success correlates with ad-herence to ongoing use of the device. (C)

CGM may be a supplemental tool toSMBG in those with hypoglycemia un-awareness and/or frequent hypoglyce-

mic episodes. (E)

A1C Perform the A1C test at least two times

a year in patients who are meeting treat-ment goals (and who have stable glyce-mic control). (E)

Perform the A1C test quarterly in pa-tients whose therapy has changed orwho arenot meeting glycemic goals. (E)

Use of point-of-care testing for A1C al-lows for timely decisions on therapychanges, when needed. (E)

DOI: 10.2337/dc09-S006 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.

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Glycemic Goals in Adults Lowering A1C to below or around 7%

has been shown to reduce microvascu-lar and neuropathic complications oftype 1 and type 2 diabetes. Therefore,for microvascular disease prevention,the A1C goal for nonpregnant adults ingeneral is 7%. (A)

In type 1 and type 2 diabetes, random-ized controlled trials of intensive versusstandard glycemic control have notshown a significant reduction in CVDoutcomes during the randomized por-tion of the trials. Long-term follow-upof the Diabetes Control and Complica-tions Trial (DCCT) and UK ProspectiveDiabetes Study (UKPDS) cohorts sug-gests that treatment to A1C targets be-low or around 7% in the years soonafter the diagnosis of diabetes is associ-ated with long-term reduction in risk of

macrovascular disease. Until more evi-dence becomes available, the generalgoal of7% appears reasonable formany adults for macrovascular risk re-duction. (B)

Subgroup analyses of clinical trials suchas the DCCT and UKPDS and the mi-crovascular evidence from the AD-

VANCE (Action in Diabetes andVascular Disease: Preterax and Diami-cron MR Controlled Evaluation) trialsuggest a small but incremental benefitin microvascular outcomes with A1Cvalues closer to normal. Therefore, for

selected individual patients, providersmight reasonably suggest even lower

A1C goals than the general goal of7%, if this can be achieved withoutsignificant hypoglycemia or other ad-verse effects of treatment. Such patientsmight include those with short dura-tion of diabetes, long life expectancy,and no significant CVD. (B)

Conversely, less stringent A1C goalsthan the general goal of7% may beappropriate for patients with a historyof severe hypoglycemia, limited life ex-

pectancy, advanced microvascular ormacrovascular complications, and ex-tensive comorbid conditions and thosewith longstanding diabetes in whomthe general goal is difficult to attain de-spite diabetes self-management educa-tion, appropriate glucose monitoring,and effective doses of multiple glucose-lowering agents including insulin. (C)

Medical Nutrition Therapy (MNT)General recommendations Individuals who have pre-diabetes or

diabetes should receive individualized

MNT as needed to achieve treatmentgoals, preferably provided by a regis-tered dietitian familiar with the compo-nents of diabetes MNT. (B)

MNT should be covered by insuranceand other payors. (E)

Energy balance, overweight, and obesity In overweight and obese insulin-

resistant individuals, modest weightloss has been shown to reduce insulinresistance. Thus, weight loss is recom-mended for all overweight or obese in-dividuals who have or are at risk fordiabetes. (A)

For weight loss, either low-carbohy-drate or low-fat calorie-restricted dietsmay be effective in the short-term (upto 1 year) (A).

For patients on low-carbohydrate diets,monitor lipid profiles, renal function,

and protein intake (in those with ne-phropathy) and adjust hypoglycemictherapy as needed. (E)

Physical activity and behavior modifica-tion are important components of weightloss programs and are most helpful inmaintenance of weight loss. (B)

Primary prevention of diabetes Among individuals at high risk for de-

veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges and include moderate weightloss (7% body weight) and regular

physical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietaryfat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A)

Individualsat highrisk fortype 2 diabetesshould be encouragedto achieve the U.S.Department of Agriculture recommenda-tion for dietary fiber (14 g fiber/1,000kcal) and foods containing whole grains(one-half of grain intake). (B)

Dietary fat intake in diabetes manage-ment Saturated fat intake should be 7% of

total calories. (A) Intake oftrans fatshouldbe minimized. (B)

Carbohydrate intake in diabetes man-agement Monitoring carbohydrate, whether by

carbohydrate counting, exchanges, orexperience-based estimation, remains akey strategy in achieving glycemic con-trol. (A)

For individuals with diabetes,the useof

the glycemic index and glycemic loadmay provide a modest additional bene-fit for glycemic control over that ob-served when total carbohydrate isconsidered alone. (B)

Other nutrition recommendations Sugar alcohols and nonnutritive sweet-

eners are safe when consumed withinthe acceptable daily intake levels estab-lished by the Food and Drug Adminis-tration. (A)

If adults with diabetes choose to usealcohol, daily intake should be limitedto a moderate amount (one drink perday or less for adult women and twodrinks per day or less for adult men).(E)

Routine supplementation with antioxi-dants, such as vitamins E and C andcarotene, is not advised because of lack

of evidence of efficacy and concern re-lated to long-term safety. (A) Benefit from chromium supplementa-

tion in people with diabetes or obesityhas not been conclusively demon-strated and, therefore, cannot be rec-ommended. (E)

Bariatric Surgery Bariatric surgery should be considered

for adults with BMI 35 kg/m2 andtype 2 diabetes, especially if the diabe-tes is difficult to control with lifestyleand pharmacologic therapy. (B)

Patients with type 2 diabetes who haveundergone bariatric surgery need life-long lifestyle support and medicalmonitoring. (E)

Although small trials have shown gly-cemic benefit of bariatric surgery in pa-tients with type 2 diabetes and BMI of3035 kg/m2, there is currently insuf-ficient evidence to generally recom-mend surgery in patients with BMI35kg/m2 outside of a research protocol.(E)

T h e l o n g - t e r m b e n e fi t s , c o s t -

effectiveness, and risks of bariatric sur-gery in individuals with type 2 diabetesshould be studied in well-designed ran-domized controlled trials with optimalmedical and lifestyle therapy as thecomparator. (E)

Diabetes Self-ManagementEducation (DSME) People with diabetes should receive

DSME according to national standardswhen their diabetes is diagnosed and asneeded thereafter. (B)

Self-management behavior change is

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primary goal is an LDL cholesterol100 mg/dl (2.6 mmol/l). (A)

In individuals with overt CVD, a lowerLDL cholesterol goal of70 mg/dl (1.8mmol/l), using a high dose of a statin, isan option. (B)

If drug-treated patients do notreach theabove targets on maximal tolerated sta-

tin therapy, a reduction in LDL choles-terol of3040% from baseline is analternative therapeutic goal. (A)

Triglyceride levels 150 mg/dl (1.7mmol/l) and HDL cholesterol 40mg/dl (1.0 mmol/l) in men and 50mg/dl (1.3 mmol/l) in women are desir-able. However, LDL cholesteroltargeted statin therapy remains thepreferred strategy. (C)

If targets are not reached on maximallytolerated doses of statins, combinationtherapy using statins and other lipid-

lowering agents may be considered toachieve lipid targets but has not beenevaluated in outcome studies for eitherCVD outcomes or safety. (E)

Statin therapy is contraindicated inpregnancy. (E)

Antiplatelet Agents Use aspirin therapy (75162 mg/day)

as a primary prevention strategy inthose with type 1 or type 2 diabetes atincreased cardiovascular risk, includ-ing those who are 40 years of age or

who have additional risk factors (familyhistory of CVD, hypertension, smok-ing, dyslipidemia, or albuminuria). (C)

Use aspirin therapy (75162 mg/day)as a secondary prevention strategy inthose with diabetes with a history ofCVD. (A)

For patients with CVD and docu-mented aspirin allergy, clopidogrel (75mg/day) should be used. (B)

Combination therapy with ASA (75162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after

an acute coronary syndrome. (B) Aspirin therapy is not recommended in

people under 30 years of age, due tolack of evidence of benefit, and is con-traindicated in patients under the age of21 years because of the associated riskof Reyes syndrome. (E)

Smoking Cessation Advise all patients not to smoke. (A) Include smoking cessation counseling

and other forms of treatment as a rou-tine component of diabetes care. (B)

Coronary Heart Disease (CHD)Screening and TreatmentScreening In asymptomatic patients, evaluate risk

factors to stratify patients by 10-yearrisk and treat risk factors accordingly.(B)

Treatment In patients with known CVD, ACE in-

hibitor (C), aspirin (A), and statin ther-apy (A) (if not contraindicated) shouldbe used to reduce the risk of cardiovas-cular events.

In patients with a prior myocardial in-farction, add -blockers (if not contra-indicated) to reduce mortality. (A)

In patients 40 years of age with an-other cardiovascular risk factor (hyper-tension, family history, dyslipidemia,microalbuminuria, cardiac autonomic

neuropathy, or smoking), aspirin andstatin therapy (if not contraindicated)should be used to reduce the risk ofcardiovascular events. (B)

In patients with coronary heart failure(CHF), thiazolidinedione use is contra-indicated. (C)

Metformin may be used in patients withstable CHF if renal function is normal.It should be avoided in unstable or hos-pitalized patients with CHF. (C)

Nephropathy Screening andTreatment

General recommendations To reduce the risk or slow the progres-

sion of nephropathy, optimize glucosecontrol. (A)

To reduce the risk or slow the progres-sion of nephropathy, optimize bloodpressure control. (A)

Screening Perform an annual test to assess urine

albumin excretion (UAE) in type 1 dia-betic patients with diabetes duration of5 years and in all type 2 diabetic pa-

tients, starting at diagnosis. (E) Measure serum creatinine at least annu-ally in all adults with diabetes regard-less of the degree of UAE. The serumcreatinine should be used to estimateGFR and stage the level of chronic kid-ney disease (CKD), if present. (E)

Treatment In the treatment of the nonpregnant pa-

tient with micro- or macroalbuminuria,either ACE inhibitors or ARBs shouldbe used. (A)

While there are no adequate head-to-

head comparisons of ACE inhibitorsand ARBs, there is clinical trial supportfor each of the following statements: In patients with type 1 diabetes, with

hypertension and any degree of albu-minuria, ACE inhibitors have beenshown to delay the progression of ne-phropathy. (A)

In patients with type 2 diabetes, hy-pertension, and microalbuminuria,both ACE inhibitors and ARBs havebeen shown to delay the progressionto macroalbuminuria. (A)

In patients with type 2 diabetes, hy-pertension, macroalbuminuria, andrenal insufficiency (serum creatinine1.5 mg/dl), ARBs have been shownto delay the progression of nephrop-athy. (A)

If one class is not tolerated, the othershould be substituted. (E)

Reduction of protein intake to 0.81.0g kg body wt1 day1 in individualswith diabetes and the earlier stages ofCKD and to 0.8 g kg body wt1 day1 in the later stages of CKD mayimprove measures of renal function(UAE rate, GFR) and is recommended(B)

When ACE inhibitors, ARBs, or diuret-ics are used, monitor serum creatinineand potassium levels for the develop-ment of acute kidney disease and hy-perkalemia. (E)

Continued monitoring of UAE to assess

both response to therapy and progres-sion of disease is recommended. (E)

Consider referral to a physician experi-enced in the care of kidney diseasewhen there is uncertainty about the eti-ology of kidney disease (active urinesediment, absence of retinopathy, rapiddecline in GFR), difficult managementissues, or advanced kidney disease. (B)

Retinopathy Screening andTreatmentGeneral recommendations

To reduce the risk or slow the progres-sion of retinopathy, optimize glycemiccontrol. (A)

To reduce the risk or slow the progres-sion of retinopathy, optimize bloodpressure control. (A)

Screening Adults and children aged 10 years or

older with type 1 diabetes should havean initial dilated and comprehensiveeye examination by an ophthalmologistor optometrist within 5 years after theonset of diabetes. (B)

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Patients with type 2 diabetes shouldhave an initial dilated and comprehen-sive eyeexamination by an ophthalmol-ogist or optometrist shortly after thediagnosis of diabetes. (B)

Subsequent examinations for type 1and type 2 diabetic patients should berepeated annually by an ophthalmolo-

gist or optometrist. Less frequent exams(every 23 years) may be consideredfollowing one or more normal eye ex-ams. Examinations will be requiredmore frequently if retinopathy is pro-gressing. (B)

Women with preexisting diabetes whoare planning pregnancy or who havebecome pregnant should have a com-prehensive eye examination and becounseled on the risk of developmentand/or progression of diabetic retinop-athy. Eye examination should occur in

the first trimester with close follow-upthroughout pregnancy and for 1 yearpostpartum. (B)

Treatment Promptly refer patients with any level of

macular edema, severe nonproliferativediabetic retinopathy (NPDR), or anyproliferative diabetic retinopathy(PDR) to an ophthalmologist who isknowledgeable and experienced in themanagement and treatment of diabeticretinopathy. (A)

Laser photocoagulation therapy is indi-

cated to reduce the risk of vision loss inpatients with high-risk PDR, clinicallysignificant macular edema, and in somecases of severe NPDR. (A)

The presence of retinopathy is not acontraindication to aspirin therapy forcardioprotection, as this therapy doesnot increase the risk of retinal hemor-rhage. (A)

Neuropathy Screening andTreatment All patients should be screened for dis-

tal symmetric polyneuropathy (DPN) atdiagnosis and at least annually thereaf-ter using simple clinical tests. (B)

Electrophysiological testing is rarelyneeded, except in situations where theclinical features are atypical. (E)

Screening for signs and symptoms ofcardiovascular autonomic neuropathyshould be instituted at diagnosis of type2 diabetes and 5 years after the diagno-sis of type 1 diabetes. Special testing israrely needed and may not affect man-agement or outcomes. (E)

Medications for the relief of specific

symptoms related to DPN and auto-nomic neuropathy are recommended,as they improve the quality of life of thepatient. (E)

Foot care For all patients with diabetes, perform

an annual comprehensive foot exami-nation to identify risk factors predictiveof ulcers and amputations. The foot ex-amination should include inspection,assessment of foot pulses, and testingfor loss of protective sensation (10-gmonofilament plus testing any one of:vibration using 128-Hz tuning fork,pinprick sensation, ankle reflexes, orvibration perception threshold). (B)

Provide general foot self-care educationto all patients with diabetes. (B)

A multidisciplinary approach is recom-mended for individuals with foot ulcers

and high-risk feet, especially those witha history of prior ulcer or amputation.(B)

Refer patients who smoke, have loss ofprotective sensation and structural ab-normalities, or have history of priorlower-extremity complications to footcare specialists for ongoing preventivecare and life-long surveillance. (C)

Initial screening for peripheral arterialdisease (PAD) should include a historyfor claudication and an assessment ofthe pedal pulses. Consider obtaining anankle-brachial index (ABI), as many pa-tients with PAD are asymptomatic. (C)

Refer patients with significant claudica-tion or a positive ABI for further vascu-lar assessment and consider exercise,medications, and surgical options. (C)

Children and AdolescentsGlycemic control Consider age when setting glycemic

goals in children and adolescents withtype 1 diabetes,with less stringentgoalsfor younger children. (E)

Nephropathy

Annual screening for microalbumin-uria, with a random spot urine samplefor microalbumin-to-creatinine ratio,should be initiated once the child is 10years of age and has had diabetes for 5years. (E)

Confirmed, persistently elevated mi-croalbumin levels on two additionalurine specimens should be treated withan ACE inhibitor, titrated to normaliza-tion of microalbumin excretion if pos-sible. (E)

Hypertension Treatment of high-normal blood pres-

sure (systolic or diastolic blood pres-sure consistently between the 9095thpercentile for age, sex, and height)should include dietary interventionand exercise, aimed at weight controland increased physical activity, if ap-

propriate. If target blood pressure is notreached with 612 months of lifestyleintervention, pharmacologic treatmentshould be initiated. (E)

Pharmacologic treatment of high bloodpressure (systolic or diastolic bloodpressure consistently above the 95thpercentile for age, sex, and height orconsistently 130/80 mmHg for ado-lescents) should be initiated along withlifestyle intervention as soon as the di-agnosis is confirmed. (E)

ACE inhibitors should be considered

for the initial treatment of hyperten-sion. (E) The goal of treatment is a blood pres-

sure consistently130/80 or below the90th percentile for age, sex, and height,whichever is lower. (E)

DyslipidemiaScreening If there is a family history of hypercho-

lesterolemia (total cholesterol 240mg/dl) or a cardiovascular event beforeage 55 years, or if family history is un-known, then a fasting lipid profile

should be performed on children 2years of age soon after diagnosis (afterglucose control has been established).If family history is not of concern, thenthe first lipid screening should be per-formed at puberty (10 years). Allchil-dren diagnosed with diabetes at or afterpuberty should have a fasting lipid pro-file performed soon after diagnosis(after glucose control has been estab-lished). (E)

For both age-groups, if lipidsare abnor-mal, annual monitoring is recom-

mended. If LDL cholesterol values arewithin the accepted risk levels (100mg/dl [2.6 mmol/l]), a lipid profileshould be repeated every 5 years. (E)

Treatment Initial therapy should consist of optimi-

zation of glucose control and MNTusing a Step 2 American Heart Associ-ation diet aimed at a decrease in theamount of saturated fat in the diet. (E)

After the age of 10 years, the addition ofa statin is recommended in patientswho, after MNT and lifestyle changes,

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All patients with diabetes admitted tothe hospital should have an A1C ob-tained if the result of testing in the pre-vious 23 months is not available. (E)

A diabetes education planincluding sur-vival skills education and follow-upshould be developed for each patient. (E)

Patients with hyperglycemia in the hos-

pital who do not have a diagnosis ofdiabetes should have appropriate plansfor follow-up testing and care docu-mented at discharge. (E)

Diabetes Care in the School and DayCare Setting An individualized Diabetes Medical

Management Plan (DMMP) should bedeveloped by the parent/guardian andthe students personal diabetes healthcare team with input from the parent/guardian. (E)

All school staff members who have re-sponsibility for a student with diabetesshould receive training that provides abasic understanding of diabetes and astudents needs. (E)

While the schoolnurse is the coordinatorand primary provider of diabetes care, asmall numberof school personnel shouldbe trained in routine and emergency dia-betes procedures (including monitoringof blood glucose levels and administra-tion of insulin and glucagon) and in theappropriate response to high and low

blood glucose levels and should performthese diabetes care tasks when the schoolnurse is not available to do so. Theseschool personnel need not be health careprofessionals. (E)

As specified in the DMMP and as devel-opmentally appropriate, the studentwith diabetes should have immediateaccess to diabetes supplies at all timesand should be permitted to self-managehis or her diabetes in the classroom oranywhere the student may be in con-

junction with a school activity. Such

self-management should include bloodglucose monitoring and responding to

blood glucose levels with needed foodand medication. (E)

Diabetes Care at Diabetes Camps Each camper should have a standard-

ized medical form completed by his/herfamily and the physician managing thediabetes. (E)

Camp medical staff should be led by aphysician with expertise in managingtype 1 and type 2 diabetes and shouldinclude nurses (including diabetes ed-ucators and diabetes clinical nurse spe-cialists) and registered dietitians withexpertise in diabetes. (E)

All camp staff, including physicians,nurses, dietitians, and volunteers,should undergo background testing toensure appropriateness in workingwith children. (E)

Diabetes Management inCorrectional Institutions Correctional staff should be trained in

the recognition, treatment, and appro-priate referral for hypo- and hypergly-cemia, including serious metabolicdecompensation. (E)

Patients with a diagnosis of diabetesshould have a complete medical historyand physical examination by a licensedhealth care provider with prescriptiveauthority in a timely manner upon en-try. Insulin-treated patients shouldhave a capillary blood glucose (CBG)

determination within 12 h of arrival.Staff should identify patients with type1 diabetes who are at high risk for dia-betic ketoacidosis with omission of in-sulin. (E)

Medications and MNT should be con-tinued without interruption upon entryinto the correctional environment. (E)

In the correctional setting, policies andprocedures should enable CBG moni-toring to occur at the frequency neces-sitated by the patients glycemic controland diabetes regimen and should re-

quire staff to notify a physician of allCBG results outside of a specified

range, as determined by the treatingphysician. (E)

For all inter-institutional transfers, amedical transfer summary should betransferred with the patient, and diabe-tes supplies and medication should ac-company the patient. (E)

Correctional staff should begin dis-

charge planning with adequate leadtime to ensure continuity of care andfacilitate entry into community diabe-tes care. (E)

Emergency and DisasterPreparedness People with diabetes should maintain a

disaster kit that includes items impor-tant to their diabetes self-managementand continuing medical care. (E)

The kit should be reviewed and replen-ished at least twice yearly. (E)

Diabetes and Employment When questions arise about the medical

fitness of a person with diabetes fora par-ticular job,a healthcare professionalwithexpertise in treating diabetes should per-form an individualized assessment; inputfromthe treating physician should alwaysbe included. (E)

Proper safety assessments for employ-ment should include review of bloodglucose test results, history of severehypoglycemia, presence of hypoglyce-mia unawareness, and presence of dia-

betes-related complications but shouldnot include urine glucose or A1C/eAG(estimated average glucose) tests or bebased on a general assessment of levelof control. (E)

Third-Party Reimbursement forDiabetes Care, Self-ManagementEducation, and Supplies Patients and practitioners should

have access to all classes of antidiabe-tes medications, equipment, and sup-plies without undue controls. (E)

MNT and DSME should be covered byinsurance and other payors. (E)

Executive Summary


ada std of dm care 2009 exe summary

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