Depicted are patient and disease factors used to determine optimal A1C targets. Characteristics and predicaments toward the left justify more stringent efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.
Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). DPP-4-i, DPP-4 inhibitor; fxs, fractures; GI, gastrointestinal; GLP-1 RA, GLP-1 receptor agonist; GU, genitourinary; HF, heart failure; Hypo, hypoglycemia; SGLT2-i, SGLT2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione. *See original source for description of efficacy categorization. §Usually a basal insulin (NPH, glargine, detemir, degludec). Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.
Combination injectable therapy for type 2 diabetes. FBG, fasting blood glucose; GLP-1 RA, GLP-1 receptor agonist; hypo, hypoglycemia. Adapted with permission from Inzucchi et al. Diabetes Care 2015;38:140–149.
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the Diabetes Control and Complications Trial assay.*
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).
↵*In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.
Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults
Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the following risk factors:
A1C ≥5.7% (39 mmol/mol), impaired glucose tolerance, or impaired fasting glucose on previous testing
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
For all patients, testing should begin at age 45 years.
If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status.
Referrals for Initial Care Management
Eye care professional for annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for MNT
DSME and DSMS
Dentist for comprehensive dental and periodontal examination
Mental health professional, if indicated
Components of the Comprehensive Diabetes Medical Evaluation*
Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis [DKA], asymptomatic laboratory finding)
Eating patterns, nutritional status, weight history, sleep behaviors (pattern and duration), and physical activity habits; nutrition education and behavioral support history and needs
Complementary and alternative medicine use
Presence of common comorbidities and dental disease
Screen for depression, anxiety, and disordered eating using validated and appropriate measures**
Screen for diabetes distress using validated and appropriate measures**
Screen for psychosocial problems and other barriers to diabetes self-management such as limited financial, logistical, and support resources
History of tobacco use, alcohol consumption, and substance use
DSME and DSMS history and needs
Review of previous treatment regimens and response to therapy (A1C records)
Assess medication-taking behaviors and barriers to medication adherence
Results of glucose monitoring and patient’s use of data
DKA frequency, severity, and cause
Hypoglycemia episodes, awareness, frequency, and causes
History of increased blood pressure and abnormal lipids
Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
For women with child-bearing capacity, review contraception and preconception planning
Height, weight, and BMI; growth and pubertal development in children and adolescents
Blood pressure determination, including orthostatic measurements when indicated
Skin examination (e.g., for acanthosis nigricans and insulin injection or infusion set insertion sites)
Comprehensive foot examination:
○ Palpation of dorsalis pedis and posterior tibial pulses
○ Presence/absence of patellar and Achilles reflexes
○ Determination of proprioception, vibration, and monofilament sensation
A1C, if results not available within the past 3 months
If not performed/available within the past year:
○ Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed
○ Liver function tests
○ Spot urinary albumin–to–creatinine ratio
○ Serum creatinine and eGFR
○ Thyroid-stimulating hormone in patients with type 1 diabetes
↵*The comprehensive medical evaluation should all ideally be done on the initial visit, but if time is limited different components can be done as appropriate on follow-up visits.
↵**Refer to the ADA position statement “Psychochsocial Care for People With Diabetes” for additional details on diabetes-specific screening measures.
Effectiveness of nutrition therapy
• An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes.
• For people with type 1 diabetes and those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting and, in some cases, fat and protein gram estimation to determine mealtime insulin dosing can improve glycemic control.
• For individuals whose daily insulin dosing is fixed, having a consistent pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia.
• A simple and effective approach to glycemia and weight management emphasizing portion control and healthy food choices may be more helpful for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, or who are elderly and prone to hypoglycemia.
• Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed by insurance and other payers. E
B, A, E
• Modest weight loss achievable by the combination of reduction of caloric intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. Intervention programs to facilitate this process are recommended.
Eating patterns and macronutrient distribution
• Because there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total caloric and metabolic goals in mind.
• A variety of eating patterns are acceptable for the management of type 2 diabetes and prediabetes including the Mediterranean diet, DASH, and plant-based diets.
• Carbohydrate intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycemic load, should be advised over other sources, especially those containing sugars.
• People with diabetes and those at risk should avoid sugar-sweetened beverages to control weight and reduce their risk for CVD and fatty liver disease B and should minimize their consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices. A
• In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia.
• Whereas data on the ideal total dietary fat content for people with diabetes are inconclusive, an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates.
• Eating foods rich in long-chain ω-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA) is recommended to prevent or treat CVD B; however, evidence does not support a beneficial role for ω-3 dietary supplements. A
Micronutrients and herbal supplements
• There is no clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve outcomes in people with diabetes who do not have underlying deficiencies, and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene.
• Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men).
• Alcohol consumption may place people with diabetes at increased risk for hypoglycemia, especially if they are taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted.
• As for the general population, people with diabetes should limit sodium consumption to <2,300 mg/day, although further restriction may be indicated for those with both diabetes and hypertension.
• The use of nonnutritive sweeteners has the potential to reduce overall caloric and carbohydrate intake if substituted for caloric sweeteners and without compensation by intake of additional calories from other food sources. Nonnutritive sweeteners are generally safe to use within the defined acceptable daily intake levels.
Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes
↵* More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.
↵† Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.
Recommendations for Statin and Combination Treatment in People With Diabetes
• Yearly measurement of UACR, serum creatinine, and potassium
• Refer to a nephrologist if possibility for nondiabetic kidney disease exists (duration of type 1 diabetes <10 years, persistent albuminuria, abnormal findings on renal ultrasound, resistant hypertension, rapid fall in eGFR, or active urinary sediment on urine microscopic examination)
• Consider the need for dose adjustment of medications
• Monitor eGFR every 6 months
• Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, and parathyroid hormone at least yearly
• Assure vitamin D sufficiency
• Vaccinate against hepatitis B virus
• Consider bone density testing
• Refer for dietary counseling
• Monitor eGFR every 3 months
• Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin, and weight every 3–6 months
• Consider the need for dose adjustment of medications
• Refer to a nephrologist
Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults With Diabetes
Consider likelihood of benefit with statin (secondary prevention more so than primary)
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time. ADL, activities of daily living.
↵‡ A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.
↵* Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, myocardial infarction, and stroke. By “multiple,” we mean at least three, but many patients may have five or more.
↵** The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
↵† A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of ∼200 mg/dL (11.1 mmol/L). Looser A1C targets >8.5% (69 mmol/mol) are not recommended because they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.