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Standards of Medical Care in Diabetes2006

AMERICAN DIABETES ASSOCIATION

CONTENTS

I. CLASSIFICATIONANDDIAGNOSIS,

p. S4A. Classification

B. DiagnosisII. SCREENING FOR DIABETES,

p. S5

III. DETECTION AND DIAGNOSIS

OF GESTATIONAL DIABETES

MELLITS, p. S!

I". #RE"ENTION$DELA% OF T%#E &

DIABETES, p. S!

". DIABETES CARE, p. S'

A. Initial ()al*ation

B. Manag(+(nt

C. Glc(+ic cont-ol

. Ass(ss+(nt of glc(+iccont-ol

a. S(lf/+onito-ing of

0loo1 gl*cos(

0. AC&. Glc(+ic goals

D. M(1ical n*t-ition t2(-ap

E. Dia0(t(s s(lf/+anag(+(nt (1*cation

F. #2sical acti)it

G. #sc2osocial ass(ss+(nt an1 ca-(

3. R(f(--al fo- 1ia0(t(s +anag(+(nt

I. Int(-c*--(nt illn(ss

. 3poglc(+ia. I++*ni6ation

"I. #RE"ENTION AND MANAGEMENT

OF DIABETES COM#LICATIONS,

p. S!

A. Ca-1io)asc*la- 1is(as(

. 3p(-t(nsion$0loo1 p-(ss*-(cont-ol

&. Dslipi1(+ia$lipi1 +anag(+(nt

7. Antiplat(l(t ag(nts

4. S+o8ing c(ssation5. Co-ona- 2(a-t 1is(as( sc-((ning

an1 t-(at+(ntB. N(p2-opat2 sc-((ning an1

t-(at+(nt

C. R(tinopat2 sc-((ning an1

t-(at+(nt

D. N(*-opat2 sc-((ning an1

t-(at+(nt

E. Foot ca-(

"II. DIABETES CARE IN S#ECIFIC

#O#LATIONS, p. S&9

A. C2il1-(n an1 a1ol(sc(nts

B. #-(conc(ption ca-(

C. Ol1(- in1i)i1*als

"III. DIABETES CARE IN S#ECIFICSETTINGS, p. S&:

A. Dia0(t(s ca-( in t2( 2ospitalB. Dia0(t(s ca-( in t2( sc2ool an1

1a ca-( s(tting

C. Dia0(t(s ca-( at 1ia0(t(s ca+ps

D. Dia0(t(s +anag(+(nt in co--(ctional

instit*tions

I;. 3%#OGL%CEMIA AND EM#LO%MENT$

LICENSRE, p. S74

;. T3IRD/#ART% REIMBRSEMENT

FOR DIABETES CARE, SELFMANAGEMENT

EDCATION,

AND S##LIES, p. S74

;I. STRATEGIES FOR IM#RO"INGDIABETES CARE, p. S74

Dia0(t(s is a c2-onic illn(ss t2at -(it2 1ia0(t(s.

A g-a1ing sst(+ Ta0l( , 1()(lop(1 0

t2( A+(-ican Dia0(t(s Association ADA


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an1 +o1(l(1 aft(- (=isting +(t2o1s, >as

*tili6(1 to cla-if an1 co1if t2( ()i1(nc(

t2at fo-+s t2( 0asis fo- t2( -(co++(n1ations.

T2( l()(l of ()i1(nc( t2at s*ppo-ts

(ac2 -(co++(n1ation is list(1 aft(- (ac2-(co++(n1ation *sing t2( l(tt(-s A, B, C,

o- E.I. CASSI!ICATION AND

DIA"NOSIS

A. Classification

In ::!, t2( ADA iss*(1 n(> 1iagnostic

an1 classification c-it(-ia 4 in &7,

+o1ifications >(-( +a1( -(ga-1ing t2(

1iagnosis of i+pai-(1 fasting gl*cos(

IFG 5. T2( classification of 1ia0(t(s

incl*1(s fo*- clinical class(s

Tp( 1ia0(t(s -(s*lts f-o+ /c(ll 1(st-*ction,

*s*all l(a1ing to a0sol*t(

ins*lin 1(fici(nc. Tp( & 1ia0(t(s -(s*lts f-o+ a p-og-(ssi)(

ins*lin s(c-(to- 1(f(ct on t2(

0ac8g-o*n1 of ins*lin -(sistanc(.

Ot2(- sp(cific tp(s of 1ia0(t(s 1*( toot2(- ca*s(s, (.g., g(n(tic 1(f(cts in

O-iginall app-o)(1 :''. Most -(c(nt

-()i(>$-()ision, Octo0(- &5.

Abbre#iations$ ABI, an8l(/0-ac2ial in1(= AMI,

ac*t( +ocat1ial infa-ction ARB, angiot(nsin-(c(pto- 0loc8(-

CAD, co-ona- a-t(- 1is(as( CBG, capilla-

0loo1 gl*cos( C3D, co-ona- 2(a-t 1is(as( C3F,

cong(sti)(

2(a-t fail*-( CD, c2-onic 8i1n( 1is(as( C"D,

ca-1io)asc*la- 1is(as( DCCB, 1i21-op-i1in(calci*+ c2ann(l

0loc8(- DCCT, Dia0(t(s Cont-ol an1

Co+plications T-ial DA, 1ia0(tic 8(toaci1osis

DMM#, 1ia0(t(s +(1ical+anag(+(nt plan D#N, 1istal s++(t-ic

poln(*-opat2 D##, Dia0(t(s #-()(ntion#-og-a+ DRI, 1i(ta-

-(f(-(nc( inta8( DRS, Dia0(tic R(tinopat2

St*1 DSME, 1ia0(t(s s(lf/+anag(+(nt

(1*cation DSMT, 1ia0(t(s

s(lf/+anag(+(nt t-aining ECG,

(l(ct-oca-1iog-a+ ESRD, (n1/stag( -(nal 1is(as(

ETDRS, Ea-l T-(at+(nt

Dia0(tic R(tinopat2 St*1 FDA, Foo1 an1 D-*g

A1+inist-ation F#G, fasting plas+a gl*cos(

GDM, g(stational

1ia0(t(s +(llit*s GFR, glo+(-*la- filt-ation -at(

3RC, 2ig2/-is8 c2a-act(-istic IC, int(nsi)( ca-(*nit IFG,

i+pai-(1 fasting gl*cos( IGT, i+pai-(1 gl*cos(tol(-anc( MNT, +(1ical n*t-ition t2(-ap N#DR,

nonp-olif(-ati)(

1ia0(tic -(tinopat2 OGTT, o-al gl*cos( tol(-anc(

t(st #AD, p(-ip2(-al a-t(-ial 1is(as( #DR,

p-olif(-ati)(

1ia0(tic -(tinopat2 ##G, postp-an1ial plas+a

gl*cos( RDA, -(co++(n1(1 1i(ta- allo>anc(

SMBG, s(lf+onito-ing

of 0loo1 gl*cos( THD, t2ia6oli1in(1ion(

#DS, .. #-osp(cti)( Dia0(t(s St*1.

&9 0 t2( A+(-ican Dia0(t(s Association.

% O S I T I O N S T A T E M E N TS4 DIABETES CARE, "OLME &:,

S##LEMENT , ANAR% &9

/c(ll f*nction, g(n(tic 1(f(cts in ins*lin

action, 1is(as(s of t2( (=oc-in( panc-(ass*c2 as cstic fi0-osis, an1 1-*g

o- c2(+ical in1*c(1 s*c2 as in t2(

t-(at+(nt of AIDS o- aft(- o-gan t-ansplantation.

G(stational 1ia0(t(s +(llit*s GDM

1iagnos(1 1*-ing p-(gnanc.

B. Diagnosis

R(co++(n1ations

T2( F#G is t2( p-(f(--(1 t(st to 1iagnos(1ia0(t(s in c2il1-(n an1 nonp-(gnant

a1*lts. E

T2( *s( of t2( AC fo- t2( 1iagnosis of

1ia0(t(s is not -(co++(n1(1 at t2is

ti+(. E

C-it(-ia fo- t2( 1iagnosis of 1ia0(t(s innonp-(gnant a1*lts a-( s2o>n in Ta0l( &.

T2-(( >as to 1iagnos( 1ia0(t(s a-( a)aila0l(,

an1 (ac2 +*st 0( confi-+(1 on a

s*0s(


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p(opl( >2o +((t 1iagnostic c-it(-ia fo-

1ia0(t(s 0 OGTT, 0*t not 0 F#G, >ill

2a)( an AC )al*(!.K. T2( *s( of t2(

AC fo- t2( 1iagnosis of 1ia0(t(s is not

-(co++(n1(1 at t2is ti+(.3p(-glc(+ia not s*ffici(nt to +((t

t2( 1iagnostic c-it(-ia fo- 1ia0(t(s is cat(go-i6(1as (it2(- IFG o- i+pai-(1 gl*cos(

tol(-anc( IGT, 1(p(n1ing on >2(t2(- it

is i1(ntifi(1 t2-o*g2 a F#G o- an OGTT

IFG F#G +g$1l 5.9 ++ol$l to

&5 +g$1l 9.: ++ol$l

IGT &/2 plas+a gl*cos( 4 +g$1l

!.' ++ol$l to :: +g$1l .

++ol$l

R(c(ntl, IFG an1 IGT 2a)( 0((n officiall

t(-+(1 p-(/1ia0(t(s. Bot2 cat(go-i(s,

IFG an1 IGT, a-( -is8 facto-s fo-

f*t*-( 1ia0(t(s an1 ca-1io)asc*la- 1is(as(C"D.

In t2( a0s(nc( of *n(2(n 1ia0(t(s is still s*sp(ct(1

1(spit( a no-+al F#G, as >it2 t2( postpa-t*+

()al*ation of >o+(n >it2 GDM.

II. SCREENIN" !OR

DIABETESR(co++(n1ations

Sc-((ning to 1(t(ct p-(/1ia0(t(s IFG

o- IGT an1 1ia0(t(s s2o*l1 0( consi1(-(1

in in1i)i1*als 45 (a-s of ag(,

pa-tic*la-l in t2os( >it2 a BMI &5

8g$+&. Sc-((ning s2o*l1 also 0( consi1(-(1fo- p(opl( >2o a-(45 (a-s of

ag( an1 a-( o)(->(ig2t if t2( 2a)( anot2(-

-is8 facto- fo- 1ia0(t(s Ta0l( 7.

R(p(at t(sting s2o*l1 0( ca--i(1 o*t at7/(a- int(-)als. E

Sc-((n fo- p-(/1ia0(t(s an1 1ia0(t(s in2ig2/-is8, as+pto+atic, *n1iagnos(1

a1*lts an1 c2il1-(n >it2in t2( 2(alt2

ca-( s(tting. E

To sc-((n fo- 1ia0(t(s$p-(/1ia0(t(s, (it2(-

an F#G t(st o- &/2 OGTT !5/g

gl*cos( loa1 o- 0ot2 a-( app-op-iat(.

B

An OGTT +a 0( consi1(-(1 in pati(nts

>it2 IFG to 0(tt(- 1(fin( t2( -is8

of 1ia0(t(s. E

Table &'ADA evidence grading system for

clinical practice recommendations

L()(l of()i1(nc( D(sc-iption

A Cl(a- ()i1(nc( f-o+ >(ll/con1*ct(1,g(n(-ali6a0l(, -an1o+i6(1 cont-oll(1 t-ials

t2at a-( a1((-(1 incl*1ing

E)i1(nc( f-o+ a >(ll/con1*ct(1 +*ltic(nt(-

t-ial

E)i1(nc( f-o+ a +(ta/analsis t2at inco-po-at(1

(ll/con1*ct(1

-an1o+i6(1 cont-oll(1 t-ials t2at a-(a1((-(1 incl*1ing

E)i1(nc( f-o+ a >(ll/con1*ct(1 t-ial at on( o-

+o-( instit*tions

E)i1(nc( f-o+ a +(ta/analsis t2at inco-po-at(1(ll/con1*ct(1

co2o-t st*1i(s

E)i1(nc( f-o+ a >(ll/con1*ct(1 p-osp(cti)(

co2o-t st*1 o- -(gist-

E)i1(nc( f-o+ a >(ll/con1*ct(1 +(ta/analsis

of co2o-t st*1i(sS*ppo-ti)( ()i1(nc( f-o+ a >(ll/con1*ct(1 cas(/

cont-ol st*1

C S*ppo-ti)( ()i1(nc( f-o+ poo-l cont-oll(1 o-

*ncont-oll(1 st*1i(s

E)i1(nc( f-o+ -an1o+i6(1 clinical t-ials >it2

on( o- +o-( +aJo- o- t2-((o- +o-( +ino- +(t2o1ological fla>s t2at co*l1

in)ali1at( t2( -(s*lts

E)i1(nc( f-o+ o0s(-)ational st*1i(s >it2 2ig2

pot(ntial fo- 0ias s*c2 ascas( s(-i(s >it2 co+pa-ison to 2isto-ical cont-ols

E)i1(nc( f-o+ cas( s(-i(s o- cas( -(po-tsConflicting ()i1(nc( >it2 t2( >(ig2t of ()i1(nc(

s*ppo-ting t2(

-(co++(n1ation

E E=p(-t cons(ns*s o- clinical (=p(-i(nc(

Table 2'Criteria for the diagnosis of diabetes

. S+pto+s of 1ia0(t(s an1 a cas*al plas+a

gl*cos( & +g$1l . ++ol$l.


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Cas*al is 1(fin(1 as an ti+( of 1a >it2o*t

-(ga-1 to ti+( sinc( last +(al.

T2( classic s+pto+s of 1ia0(t(s incl*1( pol*-ia,

pol1ipsia, an1

*n(=plain(1 >(ig2t loss.OR

&. F#G &9 +g$1l !. ++ol$l. Fasting is 1(fin(1as no calo-ic inta8( fo- at l(ast

' 2.

OR

7. &/2 plas+a gl*cos( & +g$1l . ++ol$l

1*-ing an OGTT. T2( t(st s2o*l1

0( p(-fo-+(1 as 1(sc-i0(1 0 t2( ?o-l1 3(alt2

O-gani6ation, *sing a

gl*cos( loa1 containing t2( (at(-.

Position Statement

DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S5

T2(-( is a +aJo- 1istinction 0(t>((n 1iagnostic

t(sting an1 sc-((ning. Bot2 *tili6(

t2( sa+( clinical t(sts, >2ic2 s2o*l10( 1on( >it2in t2( cont(=t of t2( 2(alt2

ca-( s(tting. ?2(n an in1i)i1*al (=2i0its

s+pto+s o- signs of t2( 1is(as(, 1iagnostic

t(sts a-( p(-fo-+(1, an1 s*c2 t(sts

1o not -(p-(s(nt sc-((ning. T2( p*-pos(

of sc-((ning is to i1(ntif as+pto+atic

in1i)i1*als >2o a-( li8(l to 2a)( 1ia0(t(s

o- p-(/1ia0(t(s. S(pa-at( 1iagnostict(sts *sing stan1a-1 c-it(-ia a-( -(it2 tp( 1ia0(t(s

p-(s(nt >it2 ac*t( s+pto+s of 1ia0(t(san1 +a-8(1l (l()at(1 0loo1 gl*cos( l()(ls.

B(ca*s( of t2( ac*t( ons(t of s+pto+s,

+ost cas(s of tp( 1ia0(t(s a-(

1(t(ct(1 soon aft(- s+pto+s 1()(lop.?i1(sp-(a1 clinical t(sting of as+pto+atic

in1i)i1*als fo- t2( p-(s(nc( of a*toanti0o1i(s-(lat(1 to tp( 1ia0(t(s

cannot 0( -(co++(n1(1 at t2is ti+( as a

+(ans to i1(ntif in1i)i1*als at -is8. R(asons

fo- t2is incl*1( t2( follo>ing 1 c*toff

)al*(s fo- so+( of t2( i++*n( +a-8(-

assas 2a)( not 0((n co+pl(t(l (sta0lis2(1

in clinical s(ttings 2 t2(-( is no cons(ns*s

as to >2at action s2o*l1 0( ta8(n

>2(n a positi)( a*toanti0o1 t(st -(s*lt is

o0tain(1 an1 3 0(ca*s( t2( inci1(nc( of

tp( 1ia0(t(s is lo>, t(sting of 2(alt2

c2il1-(n >ill i1(ntif onl a )(- s+alln*+0(-

.5K >2o at t2at +o+(nt +a 0(p-(/1ia0(tic. Clinical st*1i(s a-( 0(ing

con1*ct(1 to t(st )a-io*s +(t2o1s of p-()(ntingtp( 1ia0(t(s in 2ig2/-is8 in1i)i1*als

(.g., si0lings of tp( 1ia0(tic

pati(nts. T2(s( st*1i(s +a *nco)(- an (ff(cti)(

+(ans of p-()(nting tp( 1ia0(t(s,

in >2ic2 cas( ta-g(t(1 sc-((ning +a 0(

app-op-iat(

in t2( f*t*-(.

Tp( & 1ia0(t(s

Tp( & 1ia0(t(s is f-(it2 1ia0(t(s +a 0( *n1iagnos(1. In1i)i1*alsat 2ig2 -is8 s2o*l1 0( sc-((n(1 fo-

1ia0(t(s an1 p-(/1ia0(t(s. C-it(-ia fo-

t(sting fo- 1ia0(t(s in as+pto+atic, *n1iagnos(1

a1*lts a-( list(1 in Ta0l( 7. T2((ff(cti)(n(ss of (a-l 1iagnosis t2-o*g2

sc-((ning of as+pto+atic in1i)i1*als

2as not 0((n 1(t(-+in(1 9.

Sc-((ning s2o*l1 0( ca--i(1 o*t

>it2in t2( 2(alt2 ca-( s(tting. Eit2(- an

F#G t(st o- &/2 OGTT !5/g gl*cos( loa1

is app-op-iat(. T2( &/2 OGTT i1(ntifi(s

p(opl( >it2 IGT, an1 t2*s, +o-( p(opl(>2o a-( at inc-(as(1 -is8 fo- t2( 1()(lop+(nt

of 1ia0(t(s an1 C"D. It s2o*l1 0(

not(1 t2at t2( t>o t(sts 1o not n(c(ssa-il

1(t(ct t2( sa+( in1i)i1*als !. It is i+po-tant

to -(cogni6( t2at alt2o*g2 t2( (fficac

of int(-)(ntions fo- p-i+a-p-()(ntion of tp( & 1ia0(t(s 2a)( 0((n

1(+onst-at(1 a+ong in1i)i1*als >it2

IGT ' @, s*c2 1ata a+ong in1i)i1*als

>it2 IFG >2o 1o not also 2a)( IGT a-(not a)aila0l(. T2( F#G t(st is +o-( con)(ni(nt

to pati(nts, +o-( -(p-o1*ci0l(,l(ss costl, an1 (asi(- to a1+inist(- t2an

t2( &/2 OGTT 4,5. T2(-(fo-(, t2( -(co++(n1(1

initial sc-((ning t(st fo- nonp-(gnant

a1*lts is t2( F#G. An OGTT

+a 0( consi1(-(1 in pati(nts >it2 IFG to

0(tt(- 1(fin( t2( -is8 of 1ia0(t(s.

T2( inci1(nc( of tp( & 1ia0(t(s in

c2il1-(n an1 a1ol(sc(nts 2as inc-(as(1


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1-a+aticall in t2( last 1(ca1(. Consist(nt

>it2 sc-((ning -(co++(n1ations fo-

a1*lts, onl c2il1-(n an1 o*t2 at inc-(as(1

-is8 fo- t2( p-(s(nc( o- t2( 1()(lop+(nt

of tp( & 1ia0(t(s s2o*l1 0(t(st(1 Ta0l( 4.

T2( (ff(cti)(n(ss of sc-((ning +aalso 1(p(n1 on t2( s(tting in >2ic2 it is

p(-fo-+(1. In g(n(-al, co++*nit

sc-((ning o*tsi1( a 2(alt2 ca-( s(tting

+a 0( l(ss (ff(cti)( 0(ca*s( of t2( fail*-(

of p(opl( >it2 a positi)( sc-((ning t(st to

s((8 an1 o0tain app-op-iat( follo>/*p

t(sting an1 ca-( o-, con)(-s(l, to (ns*-(

app-op-iat( -(p(at t(sting fo- in1i)i1*als

>2o sc-((n n(gati)(. T2at is, sc-((ning

o*tsi1( of clinical s(ttings +a i(l1 a0no-+al

t(sts t2at a-( n()(- 1isc*ss(1 >it2

a p-i+a- ca-( p-o)i1(-, lo> co+plianc(>it2 t-(at+(nt -(co++(n1ations, an1 a

)(- *nc(-tain i+pact on long/t(-+

2(alt2. Co++*nit sc-((ning +a also 0(

poo-l ta-g(t(1, i.(., it +a fail to -(ac2t2( g-o*ps +ost at -is8 an1 inapp-op-iat(l

t(st t2os( at lo> -is8 t2( >o--i(1

>(ll o- ()(n t2os( al-(a1 1iagnos(1

&,7.

On t2( 0asis of (=p(-t opinion,

sc-((ning s2o*l1 0( consi1(-(1 0 2(alt2

ca-( p-o)i1(-s at 7/(a- int(-)als 0(ginning

at ag( 45, pa-tic*la-l in t2os( >it2Table ('Criteria for testing for diabetes in

asymptomatic adult individuals

. T(sting fo- 1ia0(t(s s2o*l1 0( consi1(-(1 in all

in1i)i1*als at ag( 45 (a-s an1 a0o)(,

pa-tic*la-l in t2os( >it2 a BMI &5 8g$+&, an1, if

no-+al, s2o*l1 0( -(p(at(1 at7/(a- int(-)als.

&. T(sting s2o*l1 0( consi1(-(1 at a o*ng(- ag(

o- 0( ca--i(1 o*t +o-( f-(2o a-( o)(->(ig2t BMI &5 8g$+&an1 2a)( a11itional -is8 facto-s

a-( 2a0it*all p2sicall inacti)( 2a)( a fi-st/1(g-(( -(lati)( >it2 1ia0(t(s

a-( +(+0(-s of a 2ig2/-is8 (t2nic pop*lation

(.g., Af-ican A+(-ican, Latino,

Nati)( A+(-ican, Asian A+(-ican, #acific

Islan1(-

2a)( 1(li)(-(1 a 0a0 >(ig2ing : l0 o- 2a)(

0((n 1iagnos(1 >it2 GDM

a-( 2p(-t(nsi)( 4$: ++3g

2a)( an 3DL c2ol(st(-ol l()(l 75 +g$1l .:

++ol$l an1$o- a t-iglc(-i1( l()(l

&5 +g$1l &.'& ++ol$l

2a)( #COS

on p-()io*s t(sting, 2a1 IGT o- IFG 2a)( ot2(- clinical con1itions associat(1 >it2

ins*lin -(sistanc( (.g. #COS o-acant2osis nig-icans

2a)( a 2isto- of )asc*la- 1is(as(

Ma not 0( co--(ct fo- all (t2nic g-o*ps. #COS,

polcstic o)a- sn1-o+(.

Table )'Testing for type 2 diabetes in children

C-it(-ia

O)(->(ig2t BMI '5t2 p(-c(ntil( fo-

ag( an1 s(=, >(ig2t fo- 2(ig2t '5t2

p(-c(ntil(, o- >(ig2t &K of i1(al fo-

2(ig2t

#l*s an t>o of t2( follo>ing -is8 facto-s

Fa+il 2isto- of tp( & 1ia0(t(s in fi-sto-s(con1/1(g-(( -(lati)(

Rac($(t2nicit Nati)( A+(-ican, Af-ican

A+(-ican, Latino, Asian A+(-ican,

#acific Islan1(- Signs of ins*lin -(sistanc( o- con1itions

associat(1 >it2 ins*lin -(sistanc(

acant2osis nig-icans, 2p(-t(nsion,

1slipi1(+ia, o- #COS

Mat(-nal 2isto- of 1ia0(t(s o- GDM

Ag( of initiation ag( (a-s o- at ons(t of

p*0(-t, if p*0(-t occ*-s at a o*ng(- ag(

F-(2o 1o not +((t t2(s(

c-it(-ia.

#COS, polcstic o)a- sn1-o+(.

Standards of Medical Care

S9 DIABETES CARE, "OLME &:,


BMI &5 8g$+&. T2( -ational( fo- t2isint(-)al is t2at fals( n(gati)(s >ill 0( -(p(at(1

0(fo-( s*0stantial ti+( (laps(s,an1 t2(-( is littl( li8(li2oo1 of an in1i)i1*al

1()(loping an of t2( co+plications

of 1ia0(t(s to a significant 1(g-(( >it2in 7

(a-s of a n(gati)( sc-((ning t(st -(s*lt.

T(sting s2o*l1 0( consi1(-(1 at a o*ng(-

ag( o- 0( ca--i(1 o*t +o-( f-(2o a-( o)(->(ig2t an1 2a)(

on( o- +o-( of t2( ot2(- -is8 facto-s fo-


6/69

tp( & 1ia0(t(s.

III. DETECTION AND

DIA"NOSIS O! "DM

R(co++(n1ations

Sc-((n fo- 1ia0(t(s in p-(gnanc *sing-is8 facto- analsis an1, if app-op-iat(,

*s( of an OGTT. C ?o+(n >it2 GDM s2o*l1 0( sc-((n(1

fo- 1ia0(t(s 9@& >((8s postpa-t*+

an1 s2o*l1 0( follo>(1 *p >it2 s*0s(it2 clinical c2a-act(-istics consist(nt

>it2 a 2ig2 -is8 fo- GDM t2os( >it2

+a-8(1 o0(sit, p(-sonal 2isto- of GDM,

glcos*-ia, o- a st-ong fa+il 2isto- of

1ia0(t(s s2o*l1 *n1(-go gl*cos( t(stingas soon as possi0l( 4. An F#G &9

+g$1l o- a cas*al plas+a gl*cos( &

+g$1l +((ts t2( t2-(s2ol1 fo- t2( 1iagnosis

of 1ia0(t(s an1 n((1s to 0( confi-+(1on a s*0s(o+(n s2o*l1 0( t(st(1 0(t>((n &4 an1

&' >((8s of g(station. T(sting s2o*l1 follo>

on( of t>o app-oac2(s

On(/st(p app-oac2 p(-fo-+ a 1iagnostic/g OGTT

T>o/st(p app-oac2 p(-fo-+ an initial

sc-((ning 0 +(as*-ing t2( plas+a o-

s(-*+ gl*cos( conc(nt-ation 2 aft(- a

5/g o-al gl*cos( loa1 gl*cos( c2all(ng(

t(st an1 p(-fo-+ a 1iagnostic/g OGTT on t2at s*0s(t of >o+(n

(=c((1ing t2( gl*cos( t2-(s2ol1 )al*(

on t2( gl*cos( c2all(ng( t(st. ?2(n t2(

t>o/st(p app-oac2 is *s(1, a gl*cos(t2-(s2ol1 )al*( 4 +g$1l i1(ntifi(s

'K of >o+(n >it2 GDM, an1 t2(i(l1 is f*-t2(- inc-(as(1 to :K 0 *sing

a c*toff of 7 +g$1l.

Diagnostic c-it(-ia fo- t2( /g OGTT

a-( as follo>s :5 +g$1l fasting, '

+g$1l at 2, 55 +g$1l at & 2, an1

4 +g$1l at 7 2. T>o o- +o-( of t2(

plas+a gl*cos( )al*(s +*st 0( +(t o- (=c((1(1

fo- a positi)( 1iagnosis. T2( t(st

s2o*l1 0( 1on( in t2( +o-ning aft(- an

o)(-nig2t fast of '@4 2. T2( 1iagnosis

can 0( +a1( *sing a !5/g gl*cos( loa1,

0*t t2at t(st is not as >(ll )ali1at(1 fo-

1(t(ction of at/-is8 infants o- +ot2(-s ast2( /g OGTT.

Lo>/-is8 stat*s -(o+(n +((ting all of t2( follo>ing

c2a-act(-istics

Ag( &5 (a-s.

?(ig2t no-+al 0(fo-( p-(gnanc.

M(+0(- of an (t2nic g-o*p >it2 a lo>

p-()al(nc( of GDM.

No 8no>n 1ia0(t(s in fi-st/1(g-(( -(lati)(s.

No 2isto- of a0no-+al gl*cos( tol(-anc(.

No 2isto- of poo- o0st(t-ic o*tco+(.

I*. %RE*ENTION+DEA,

O! T,%E 2 DIABETESR(co++(n1ations

In1i)i1*als at 2ig2 -is8 fo- 1()(loping

1ia0(t(s n((1 to 0(co+( a>a-( of t2(

0(n(fits of +o1(st >(ig2t loss an1 pa-ticipatingin -(g*la- p2sical acti)it.

A

#ati(nts >it2 IGT s2o*l1 0( gi)(n

co*ns(ling on >(ig2t loss as >(ll as inst-*ction

fo- inc-(asing p2sical acti)it.

A

#ati(nts >it2 IFG s2o*l1 0( gi)(n

co*ns(ling on >(ig2t loss as >(ll as inst-*ctionfo- inc-(asing p2sical acti)it.

E

Follo>/*p co*ns(ling app(a-s i+po-tant

fo- s*cc(ss. B

Monito-ing fo- t2( 1()(lop+(nt of 1ia0(t(s

in t2os( >it2 p-(/1ia0(t(s s2o*l1 0(p(-fo-+(1 ()(- @& (a-s. E

Clos( att(ntion s2o*l1 0( gi)(n to, an1

app-op-iat( t-(at+(nt gi)(n fo-, ot2(-

C"D -is8 facto-s (.g., to0acco *s(, 2p(-t(nsion,1slipi1(+ia. A

D-*g t2(-ap s2o*l1 not 0( -o*tin(l*s(1 to p-()(nt 1ia0(t(s *ntil +o-( info-+ation

is 8no>n a0o*t its cost(ff(cti)(n(ss.

E

St*1i(s 2a)( 0((n initiat(1 in t2( last 1(ca1(

to 1(t(-+in( t2( f(asi0ilit an1 0(n(fit

of )a-io*s st-at(gi(s to p-()(nt o-

1(la t2( ons(t of tp( & 1ia0(t(s. Fi)(

>(ll/1(sign(1 -an1o+i6(1 cont-oll(1 t-ials


7/69

2a)( 0((n -(po-t(1 ' @,5,9. T2(

st-at(gi(s s2o>n to 0( (ff(cti)( in p-()(nting

1ia0(t(s -(li(1 on lif(stl( +o1ification

o- gl*cos(/lo>(-ing 1-*gs t2at

2a)( 0((n app-o)(1 fo- t-(ating 1ia0(t(s.In t2( Finnis2 st*1 :, +i11l(/ag(1

o0(s( s*0J(cts >it2 IGT >(-( -an1o+i6(1to -(c(i)( (it2(- 0-i(f 1i(t an1 (=(-cis(

co*ns(ling cont-ol g-o*p o- int(nsi)(

in1i)i1*ali6(1 inst-*ction on >(ig2t -(1*ction,

foo1 inta8(, an1 g*i1anc( on inc-(asing

p2sical acti)it int(-)(ntion

g-o*p. Aft(- an a)(-ag( follo>/*p of 7.&

(a-s, t2(-( >as a 5'K -(lati)( -(1*ction

in t2( inci1(nc( of 1ia0(t(s in t2( int(-)(ntion

g-o*p co+pa-(1 >it2 t2( cont-ol

s*0J(cts.

In t2( Dia0(t(s #-()(ntion #-og-a+

D## ', (n-oll(1 s*0J(cts >(-( slig2tlo*ng(- an1 +o-( o0(s( 0*t 2a1 n(a-l

i1(ntical gl*cos( intol(-anc( co+pa-(1

>it2 s*0J(cts in t2( Finnis2 st*1. A0o*t

45K of t2( pa-ticipants >(-( f-o+ +ino-itg-o*ps (.g., Af-ican A+(-ican, 3ispanic,

an1 &K >(-( 9 (a-s of ag(.

S*0J(cts >(-( -an1o+i6(1 to on( of t2-((

int(-)(ntion g-o*ps, >2ic2 incl*1(1 t2(

int(nsi)( n*t-ition an1 (=(-cis( co*ns(ling

lif(stl( g-o*p o- (it2(- of t>o

+as8(1 +(1ication t-(at+(nt g-o*ps t2(

0ig*ani1( +(tfo-+in g-o*p o- t2( plac(0og-o*p. T2( latt(- int(-)(ntions >(-(

co+0in(1 >it2 stan1a-1 1i(t an1 (=(-cis(

-(co++(n1ations. Aft(- an a)(-ag( follo>/

*p of &.' (a-s, a 5'K -(lati)( -(1*ction

in t2( p-og-(ssion to 1ia0(t(s >as

o0s(-)(1 in t2( lif(stl( g-o*p an1 a 7K-(lati)( -(1*ction in t2( p-og-(ssion of

1ia0(t(s >as o0s(-)(1 in t2( +(tfo-+in

g-o*p co+pa-(1 >it2 cont-ol s*0J(cts.

On a)(-ag(, 5K of t2( lif(stl( g-o*pac2i()(1 t2( goal of !K >(ig2t -(1*ction

an1 !4K +aintain(1 at l(ast 5+in$>((8 of +o1(-at(l int(ns( acti)it.

In t2( t-oglita6on( a-+ of t2( D## 1iscontin*(1

aft(- a +(an of .: (a-s >2(n

t2( 1-*g >as >it21-a>n f-o+ t2( +a-8(t,

t-oglita6on( +a-8(1l -(1*c(1 t2(

inci1(nc( of 1ia0(t(s 1*-ing t2( p(-io1

t2( 1-*g >as gi)(n 9a.

In t2( Da ing St*1 , +(n an1

>o+(n f-o+ 2(alt2 ca-( clinics in t2( cit

of Da ing, C2ina, >(-( sc-((n(1 >it2

OGTT, an1 t2os( >it2 IGT >(-( -an1o+i6(1

0 clinic to a cont-ol g-o*p o- to on(

of t2-(( acti)( t-(at+(nt g-o*ps 1i(tonl, (=(-cis( onl, o- 1i(t pl*s (=(-cis(.

S*0J(cts >(-( -((=a+in(1 0iann*all,an1 aft(- an a)(-ag( of 9 (a-sP follo>/*p,

t2( 1i(t, (=(-cis(, an1 1i(t pl*s (=(-cis(

Position Statement

DIABETES CARE, "OLME &:,

S##LEMENT , ANAR% &9 S!

int(-)(ntions >(-( associat(1 >it2 7,

49, an1 4&K -(1*ctions in -is8 of 1()(loping

tp( & 1ia0(t(s, -(sp(cti)(l.

T2-(( ot2(- st*1i(s, (ac2 *sing a 1iff(-(nt

class of gl*cos(/lo>(-ing ag(nt,

2a)( s2o>n a -(1*ction in p-og-(ssion to

1ia0(t(s >it2 p2a-+acological int(-)(ntion.In t2( T-oglita6on( in #-()(ntion of

Dia0(t(s TRI#OD st*1 5, 3ispanic

>o+(n >it2 p-()io*s GDM >(-( -an1o+i6(1

to -(c(i)( (it2(- plac(0o o- t-oglita6on(a 1-*g no> >it21-a>n f-o+

co++(-cial sal( in t2( .S. 0*t 0(longing

to t2( t2ia6oli1in(1ion( QTHD class. Aft(-

a +(1ian follo>/*p of 7 +ont2s, t-oglita6on(

t-(at+(nt >as associat(1 >it2 a

59K -(lati)( -(1*ction in p-og-(ssion to

1ia0(t(s. In t2( STO#/IDDM t-ial 9,

pa-ticipants >it2 IGT >(-( -an1o+i6(1in a 1o*0l(/0lin1 fas2ion to -(c(i)( (it2(-

t2( /gl*cosi1as( in2i0ito- aca-0os( o- a

plac(0o. Aft(- a +(an follo>/*p of 7.7

(a-s, a &5K -(lati)( -is8 -(1*ction in

p-og-(ssion to 1ia0(t(s, 0as(1 on on(

OGTT, >as o0s(-)(1 in t2( aca-0os(t-(at(1g-o*p co+pa-(1 >it2 t2( plac(0o

g-o*p. If t2is 1iagnosis >as confi-+(1 0

a s(con1 OGTT, a 79K -(lati)( -is8 -(1*ction

>as o0s(-)(1 in t2( aca-0os(g-o*p co+pa-(1 >it2 t2( plac(0o g-o*p.

Finall, in t2( ;ENical in t2( p-()(ntionof Dia0(t(s in O0(s( S*0J(cts

;ENDOS st*1, o-listat >as (=a+in(1

fo- its a0ilit to 1(la tp( & 1ia0(t(s

>2(n a11(1 to lif(stl( c2ang( in a g-o*p

>it2 BMI 7 8g$+& >it2 o- >it2o*t

IGT. Aft(- 4 (a-s of t-(at+(nt, t2( (ff(ct

of o-listat a11ition co--(spon1(1 to a

45K -is8 -(1*ction in t2( IGT g-o*p,


8/69

>it2 no (ff(ct o0s(-)(1 in t2os( >it2o*t

IGT 90.

O*- 8no>l(1g( of t2( (a-l stag(s of

2p(-glc(+ia t2at po-t(n1 t2( 1iagnosis

of 1ia0(t(s, an1 t2( -(c(nt s*cc(ss of +aJo-int(-)(ntion t-ials, cl(a-l s2o> t2at

in1i)i1*als at 2ig2 -is8 can 0( i1(ntifi(1an1 1ia0(t(s 1(la(1, if not p-()(nt(1.

T2( cost/(ff(cti)(n(ss of int(-)(ntion

st-at(gi(s is *ncl(a-, 0*t t2( 2*g( 0*-1(n

-(s*lting f-o+ t2( co+plications of 1ia0(t(s

an1 t2( pot(ntial ancilla- 0(n(fits of

so+( of t2( int(-)(ntions s*gg(st t2at an

(ffo-t to p-()(nt 1ia0(t(s is >o-t2>2il(.

Lif(stl( +o1ification

In >(ll/cont-oll(1 st*1i(s t2at incl*1(1 a

lif(stl( int(-)(ntion a-+, s*0stantial (ffo-ts

>(-( n(c(ssa- to ac2i()( onl +o1(st

c2ang(s in >(ig2t an1 (=(-cis(, 0*tt2os( c2ang(s >(-( s*ffici(nt to ac2i()(

an i+po-tant -(1*ction in t2( inci1(nc(

of 1ia0(t(s. In t2( Finnis2 Dia0(t(s #-()(ntion

St*1, >(ig2t loss a)(-ag(1 :.& l0at (a-, !.! l0 aft(- & (a-s, an1 4.9 l0

aft(- 5 (a-s : +o1(-at( (=(-cis(,

s*c2 as 0-is8 >al8ing, fo- 7 +in$1a >as

s*gg(st(1. In t2( Finnis2 st*1, t2(-( >as

a 1i-(ct -(lations2ip 0(t>((n a12(-(nc(

>it2 t2( lif(stl( int(-)(ntion an1 t2( -(1*c(1

inci1(nc( of 1ia0(t(s.

In t2( D## ', t2( lif(stl( g-o*p lost& l0 at & (a-s an1 : l0 at 7 (a-s +(an

>(ig2t loss fo- t2( st*1 1*-ation >as

& l0 o- 9K of initial 0o1 >(ig2t. In

0ot2 of t2(s( st*1i(s, +ost of t2( pa-ticipants

>(-( o0(s( BMI 7 8g$+&.

A lo>/fat &5K fat inta8( >as -(co++(n1(1if -(1*cing fat 1i1 not p-o1*c(

>(ig2t loss to goal, calo-i(

-(st-iction >as also -(co++(n1(1. #a-ticipants

>(ig2ing &@!4 l0 54@!'8g at 0as(lin( >(-( inst-*ct(1 to follo> a

,&/8cal$1a 1i(t 77 g fat, t2os( !5@&: l0 !:@:: 8g >(-( inst-*ct(1 to follo>

a ,5/8cal$1a 1i(t 4& g fat, t2os(

&& @&4: l0 @7 8g >(-( inst-*ct(1

to follo> an ,'/8cal$1a 1i(t

5 g fat, an1 t2os( &5 l0 4 8g

>(-( inst-*ct(1 to follo> a &,/8cal$

1a 1i(t 55 g fat.

#2a-+acological int(-)(ntions

T2-(( 1ia0(t(s p-()(ntion t-ials *s(1

p2a-+acological t2(-ap, an1 all 2a)( -(po-t(1

a significant lo>(-ing of t2( inci1(nc(

of 1ia0(t(s. T2( 0ig*ani1(

+(tfo-+in -(1*c(1 t2( -is8 of 1ia0(t(s 07K in t2( D## ', t2( /gl*cosi1as(

in2i0ito- aca-0os( -(1*c(1 t2( -is8 07&K in t2( STO#/IDDM t-ial 9, an1

t2( THD t-oglita6on( -(1*c(1 t2( -is8 0

59K in t2( TRI#OD st*1 5.

In t2( D##, +(tfo-+in >as a0o*t 2alf

as (ff(cti)( as 1i(t an1 (=(-cis( in 1(laing

t2( ons(t of 1ia0(t(s o)(-all, 0*t it >as

n(a-l in(ff(cti)( in ol1(- in1i)i1*als

9 (a-s of ag( o- in t2os( >2o >(-(

l(ss o)(->(ig2t BMI 7 8g$+&. Con)(-s(l,

+(tfo-+in >as as (ff(cti)( as lif(stl(

+o1ification in in1i)i1*als ag(1

&4@44 (a-s o- in t2os( >it2 a BMI 758g$+&. T2*s, t2( pop*lation of p(opl( in

>2o+ t-(at+(nt >it2 +(tfo-+in 2as

(2o a-(li8(l to 2a)( p-(/1ia0(t(s IFG o- IGT.

T2(-( a-( also 1ata to s*gg(st t2at

0loc8a1( of t2( -(nin/angiot(nsin sst(+

! +a lo>(- t2( -is8 of 1()(loping 1ia0(t(s,

0*t +o-( st*1i(s a-( n(c(ssa- 0(fo-(

t2(s( 1-*gs can 0( -(co++(n1(1 fo-

p-()(nting 1ia0(t(s.

Lif(stl( o- +(1icationT2( D## is t2( onl st*1 in >2ic2 a co+pa-ison

of t2( t>o >as +a1(, an1 lif(stl(

+o1ification >as n(a-l t>ic( as (ff(cti)(

in p-()(nting 1ia0(t(s 5' )s. 7K -(lati)(

-(1*ctions, -(sp(cti)(l. T2( g-(at(-

0(n(fit of >(ig2t loss an1 p2sical acti)itst-ongl s*gg(sts t2at lif(stl( +o1ification

s2o*l1 0( t2( fi-st c2oic( to p-()(nt

o- 1(la 1ia0(t(s. Mo1(st >(ig2t loss 5@

K of 0o1 >(ig2t an1 +o1(st p2sicalacti)it 7 +in 1ail a-( t2( -(co++(n1(1

goals. B(ca*s( t2is int(-)(ntionnot onl 2as 0((n s2o>n to p-()(nt o-

1(la 1ia0(t(s, 0*t also 2as a )a-i(t of

ot2(- 0(n(fits, 2(alt2 ca-( p-o)i1(-s

s2o*l1 *-g( all o)(->(ig2t o- s(1(nta-

in1i)i1*als to a1opt t2(s( c2ang(s, an1

s*c2 -(co++(n1ations s2o*l1 0( +a1(

at ()(- oppo-t*nit.

?2(n all facto-s a-( consi1(-(1, t2(-(


9/69

is ins*ffici(nt ()i1(nc( to s*ppo-t t2( *s(

of 1-*g t2(-ap as a s*0stit*t( fo-, o- -o*tin(l

*s(1 in a11ition to, lif(stl( +o1ification

to p-()(nt 1ia0(t(s. #*0lic 2(alt2

+(ssag(s, 2(alt2 ca-( p-of(ssionals, an12(alt2 ca-( sst(+s s2o*l1 all (nco*-ag(

0(2a)io- c2ang(s to ac2i()( a 2(alt2 lif(stl(.F*-t2(- -(s(a-c2 is n(c(ssa- to *n1(-stan1

0(tt(- 2o> to facilitat( (ff(cti)(

an1 (ffici(nt p-og-a+s fo- t2( p-i+a-

p-()(ntion of tp( & 1ia0(t(s.

*. DIABETES CARE

A. Initial ()al*ation

A co+pl(t( +(1ical ()al*ation s2o*l1 0(

p(-fo-+(1 to classif t2( pati(nt, 1(t(ct

t2( p-(s(nc( o- a0s(nc( of 1ia0(t(s co+plications,

assist in fo-+*lating a +anag(+(nt

plan, an1 p-o)i1( a 0asis fo-

contin*ing ca-(. If t2( 1iagnosis of 1ia0(t(s2as al-(a1 0((n +a1(, t2( ()al*ation

s2o*l1 -()i(> t2( p-()io*s t-(at+(nt an1

t2( past an1 p-(s(nt 1(g-((s of glc(+ic

cont-ol. La0o-ato- t(sts app-op-iat( tot2( ()al*ation of (ac2 pati(ntPs g(n(-al

+(1ical con1ition s2o*l1 0( p(-fo-+(1.

A foc*s on t2( co+pon(nts of co+p-(2(nsi)(

ca-( Ta0l( 5 >ill assist t2(

2(alt2 ca-( t(a+ to (ns*-( opti+al +anag(+(nt

of t2( pati(nt >it2 1ia0(t(s.

B. Manag(+(nt

#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)( +(1icalca-( f-o+ a p2sician/coo-1inat(1

t(a+. S*c2 t(a+s +a incl*1(, 0*t a-(

not li+it(1 to, p2sicians, n*-s( p-actition(-s,

p2sicianPs assistants, n*-s(s, 1i(titians,

p2a-+acists, an1 +(ntal 2(alt2

p-of(ssionals >it2 (=p(-tis( an1 a sp(cial


S' DIABETES CARE, "OLME &:,


int(-(st in 1ia0(t(s. It is (ss(ntial in t2iscolla0o-ati)( an1 int(g-at(1 t(a+ app-oac2

t2at in1i)i1*als >it2 1ia0(t(s ass*+(an acti)( -ol( in t2(i- ca-(.

T2( +anag(+(nt plan s2o*l1 0( fo-+*lat(1

as an in1i)i1*ali6(1 t2(-ap(*tic

allianc( a+ong t2( pati(nt an1 fa+il, t2(

p2sician, an1 ot2(- +(+0(-s of t2(

2(alt2 ca-( t(a+. An plan s2o*l1 -(cogni6(

1ia0(t(s s(lf/+anag(+(nt (1*cation

DSME as an int(g-al co+pon(nt of ca-(.

In 1()(loping t2( plan, consi1(-ation

s2o*l1 0( gi)(n to t2( pati(ntPs ag(,

sc2ool o- >o-8 sc2(1*l( an1 con1itions,

p2sical acti)it, (ating patt(-ns, social

sit*ation an1 p(-sonalit, c*lt*-al facto-s,an1 p-(s(nc( of co+plications of 1ia0(t(s

o- ot2(- +(1ical con1itions. A )a-i(t ofTable -'Components of the comprehensive

diabetes evaluation

M(1ical 2isto-

S+pto+s, -(s*lts of la0o-ato- t(sts, an1

sp(cial (=a+ination -(s*lts -(lat(1 to t2( 1iagnosis

of 1ia0(t(s

#-io- AC -(co-1s

Eating patt(-ns, n*t-itional stat*s, an1 >(ig2t

2isto- g-o>t2 an1 1()(lop+(nt in c2il1-(n an1

a1ol(sc(nts

D(tails of p-()io*s t-(at+(nt p-og-a+s,

incl*1ing n*t-ition an1 1ia0(t(s s(lf/+anag(+(nt(1*cation, attit*1(s, an1 2(alt2 0(li(fs

C*--(nt t-(at+(nt of 1ia0(t(s, incl*1ing

+(1ications, +(al plan, an1 -(s*lts of gl*cos(

+onito-ing an1 pati(ntsP *s( of 1ata E=(-cis( 2isto-

F-(it2 1ia0(t(s

Ot2(- +(1ications t2at +a aff(ct 0loo1 gl*cos(l()(ls

Ris8 facto-s fo- at2(-oscl(-osis s+o8ing,

2p(-t(nsion, o0(sit, 1slipi1(+ia, an1 fa+il

2isto- 3isto- an1 t-(at+(nt of ot2(- con1itions,

incl*1ing (n1oc-in( an1 (ating 1iso-1(-s Ass(ss+(nt fo- +oo1 1iso-1(-

Fa+il 2isto- of 1ia0(t(s an1 ot2(- (n1oc-in(

1iso-1(-s

Lif(stl(, c*lt*-al, psc2osocial, (1*cational,

an1 (cono+ic facto-s t2at +ig2t infl*(nc( t2(

+anag(+(nt of 1ia0(t(s

To0acco, alco2ol, an1$o- cont-oll(1 s*0stanc(

*s(


10/69

Cont-ac(ption an1 -(p-o1*cti)( an1 s(=*al

2isto-

#2sical (=a+ination

3(ig2t an1 >(ig2t +(as*-(+(nt an1

co+pa-ison to no-+s in c2il1-(n an1 a1ol(sc(nts S(=*al +at*-ation staging 1*-ing p*0(-tal

p(-io1 Bloo1 p-(ss*-( 1(t(-+ination, incl*1ing

o-t2ostatic +(as*-(+(nts >2(n in1icat(1, an1

co+pa-ison to ag(/-(lat(1 no-+s

F*n1oscopic (=a+ination

O-al (=a+ination

T2-oi1 palpation

Ca-1iac (=a+ination

A01o+inal (=a+ination (.g., fo- 2(pato+(gal

E)al*ation of p*ls(s 0 palpation an1 >it2

a*sc*ltation

3an1$fing(- (=a+ination

Foot (=a+ination S8in (=a+ination fo- acant2osis nig-icans an1

ins*lin/inJ(ction sit(s

N(*-ological (=a+ination

Signs of 1is(as(s t2at can ca*s( s(con1a-1ia0(t(s (.g., 2(+oc2-o+atosis, panc-(atic

1is(as(

La0o-ato- ()al*ation

AC

Fasting lipi1 p-ofil(, incl*1ing total c2ol(st(-ol,

3DL c2ol(st(-ol, t-iglc(-i1(s, an1 LDL

c2ol(st(-ol, li)(- f*nction t(sts >it2 f*-t2(-

()al*ation fo- fatt li)(- o- 2(patitis if a0no-+al T(st fo- +ic-oal0*+in*-ia in tp( 1ia0(tic

pati(nts >2o 2a)( 2a1 1ia0(t(s fo- at l(ast 5 (a-s

an1 in all pati(nts >it2 tp( & 1ia0(t(s

so+( a1)ocat( 0(ginning sc-((ning of p*0(-tal

c2il1-(n 0(fo-( 5 (a-s of 1ia0(t(s

S(-*+ c-(atinin( an1 calc*lat(1 GFR in a1*ltsc2(c8 c-(atinin( in c2il1-(n if p-ot(in*-ia is

p-(s(nt

T2-oi1/sti+*lating 2o-+on( TS3 in all tp(

1ia0(tic pati(nts in tp( & if clinicall in1icat(1 El(ct-oca-1iog-a+ in a1*lts, if clinicall

in1icat(1 -inalsis fo- 8(ton(s, p-ot(in, s(1i+(nt

R(f(--als

E( (=a+, if in1icat(1

Fa+il planning fo- >o+(n of -(p-o1*cti)( ag(

MNT, as in1icat(1

Dia0(t(s (1*cato-, if not p-o)i1(1 0 p2sician

o- p-actic( staff

B(2a)io-al sp(cialist, as in1icat(1

Foot sp(cialist, as in1icat(1

Ot2(- sp(cialti(s an1 s(-)ic(s as app-op-iat(

Position Statement


S##LEMENT , ANAR% &9 S:st-at(gi(s an1 t(c2ni


11/69

ta-g(ts a-( 0(ing ac2i()(1. R(s*lts

of SMBG can 0( *s(f*l in p-()(nting

2poglc(+ia

an1 a1J*sting +(1ications,

MNT, an1 p2sical acti)it.T2( f-(it2 ins*lin to +onito- fo- an1 p-()(nt

as+pto+atic 2poglc(+ia an1 2p(-glc(+ia.

Fo- +ost pati(nts >it2 tp(

1ia0(t(s an1 p-(gnant >o+(n ta8ing ins*lin,

SMBG is -(co++(n1(1 t2-(( o-

+o-( ti+(s 1ail. T2( opti+al f-(it2 tp(

& 1ia0(t(s on o-al ag(nt t2(-ap is not

8no>n 0*t s2o*l1 0( s*ffici(nt to facilitat(

-(ac2ing gl*cos( goals. #ati(nts >it2tp( & 1ia0(t(s on ins*lin tpicall n((1

to p(-fo-+ SMBG +o-( f-(it2 tp( & 1ia0(t(s

is not 8no>n.

B(ca*s( t2( acc*-ac of SMBG is inst-*+(nt

an1 *s(- 1(p(n1(nt &, it is

i+po-tant fo- 2(alt2 ca-( p-o)i1(-s to

()al*at( (ac2 pati(ntPs +onito-ing t(c2nio ti+(s

a (a- in pati(nts >2o a-( +((ting t-(at+(nt

goals an1 >2o 2a)( sta0l( glc(+ic

cont-ol. E

#(-fo-+ t2( AC t(st 2os( t2(-ap 2as c2ang(1 o-

>2o a-( not +((ting glc(+ic goals. E

s( of point/of/ca-( t(sting fo- AC allo>s

fo- ti+(l 1(cisions on t2(-ap

c2ang(s, >2(n n((1(1. E

B p(-fo-+ing an AC t(st, 2(alt2 p-o)i1(-s

can +(as*-( a pati(ntPs a)(-ag( glc(+ia

o)(- t2( p-(c(1ing &@7 +ont2s &an1, t2*s, ass(ss t-(at+(nt (fficac. AC

t(sting s2o*l1 0( p(-fo-+(1 -o*tin(l inall pati(nts >it2 1ia0(t(s, fi-st to 1oc*+(nt

t2( 1(g-(( of glc(+ic cont-ol at

initial ass(ss+(nt an1 t2(n as pa-t of contin*ing

ca-(. Sinc( t2( AC t(st -(fl(cts

+(an glc(+ia o)(- t2( p-(c(1ing &@7

+ont2s, +(as*-(+(nt app-o=i+at(l ()(-

7 +ont2s is -(2(t2(- a pati(ntPs +(ta0olic cont-ol 2as

0((n -(ac2(1 an1 +aintain(1 >it2in t2(

ta-g(t -ang(. T2*s, -(g*la- p(-fo-+anc(

of t2( AC t(st p(-+its 1(t(ction of 1(pa-t*-(s

f-o+ t2( ta-g(t Ta0l( 9 in ati+(l fas2ion. Fo- an in1i)i1*al pati(nt,

t2( f-(


12/69

>it2 s()(-( o- f-(it2

1ia0(t(s. UC*--(nt NCE#$AT# III g*i1(lin(s

s*gg(st t2at in pati(nts >it2 t-iglc(-i1(s &

+g$1l, t2(

non/3DL c2ol(st(-ol total c2ol(st(-ol +in*s

3DL 0( *tili6(1. T2( goal is7 +g$1l 74.

VFo- >o+(n,

it 2as 0((n s*gg(st(1 t2at t2( 3DL goal 0(

inc-(as(1 0 +g$1l.


S DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9

itations. Con1itions t2at aff(ct (-t2-oct(

t*-no)(- 2(+olsis, 0loo1 loss an1

2(+oglo0in )a-iants +*st 0( consi1(-(1,pa-tic*la-l >2(n t2( AC -(s*lt 1o(s not

co--(lat( >it2 t2( pati(ntPs clinical sit*ation

&. T2( a)aila0ilit of t2( AC -(s*lt

at t2( ti+( t2at t2( pati(nt is s((n

point of ca-( t(sting 2as 0((n -(po-t(1

to -(s*lt in t2( f-((-ing AC 2as 0((n associat(1 >it2

a -(1*ction of +ic-o)asc*la- an1 n(*-opat2ic

co+plications of 1ia0(t(s. A

T2( AC goalfor patients in general is an

AC goal of !K. B

T2( AC goalfor the individual patient is

an AC as clos( to no-+al 9K as

possi0l( >it2o*t significant 2poglc(+ia.

E L(ss st-ing(nt t-(at+(nt goals +a 0(

app-op-iat( fo- pati(nts >it2 a 2isto-of s()(-( 2poglc(+ia, pati(nts >it2

li+it(1 lif( (=p(ctanci(s, )(- o*ng

c2il1-(n o- ol1(- a1*lts, an1 in1i)i1*als

>it2 co+o-0i1 con1itions. E

Agg-(ssi)( glc(+ic +anag(+(nt >it2

ins*lin +a -(1*c( +o-0i1it in pati(nts

>it2 s()(-( ac*t( illn(ss, p(-iop(-ati)(l,

follo>ing +oca-1ial

infa-ction, an1 in p-(gnanc. B

Glc(+ic cont-ol is f*n1a+(ntal to t2(

+anag(+(nt of 1ia0(t(s. T2( goal of t2(-ap

is to ac2(i)( an AC as clos( to no-+alas possi0l( -(p-(s(nting no-+al

fasting an1 postp-an1ial gl*cos( conc(nt-ations

in t2( a0s(nc( of 2poglc(+ia.

3o>()(-, t2is goal is 1iffic*lt to ac2i()(>it2 p-(s(nt t2(-api(s &4. #-osp(cti)(

-an1o+i6(1 clinical t-ials s*c2 as t2(

DCCT &5 an1 t2( .. #-osp(cti)( Dia0(t(s

St*1 #DS &9,&! 2a)(

s2o>n t2at i+p-o)(1 glc(+ic cont-ol is

associat(1 >it2 s*stain(1 1(c-(as(1 -at(s

of -(tinopat2, n(p2-opat2, an1 n(*-opat2

&'. In t2(s( t-ials, t-(at+(nt-(gi+(ns t2at -(1*c(1 a)(-ag( AC to

!K K a0o)( t2( *pp(- li+its of

no-+al >(-( associat(1 >it2 f(>(- longt(-+

+ic-o)asc*la- co+plications 2o>()(-,

int(nsi)( cont-ol >as fo*n1 to

inc-(as( t2( -is8 of s()(-( 2poglc(+iaan1 >(ig2t gain &:,7. T2( pot(ntial of

int(nsi)( glc(+ic cont-ol to -(1*c( C"D

is s*ppo-t(1 0 (pi1(+iological st*1i(s

&5@7 an1 a -(c(nt +(ta/analsis 7,0*t t2is pot(ntial 0(n(fit on C"D ()(nts

2as not (t 0((n 1(+onst-at(1 in a -an1o+i6(1clinical t-ial.

R(co++(n1(1 glc(+ic goals fo-

nonp-(gnant in1i)i1*als a-( s2o>n in Ta0l(

9. A +aJo- li+itation to t2( a)aila0l(

1ata is t2at t2( 1o not i1(ntif t2( opti+*+

l()(l of cont-ol fo- pa-tic*la- pati(nts,

as t2(-( a-( in1i)i1*al 1iff(-(nc(s

in t2( -is8s of 2poglc(+ia, >(ig2t gain,


13/69

an1 ot2(- a1)(-s( (ff(cts. F*-t2(-+o-(,

>it2 +*ltifacto-ial int(-)(ntions, it is *ncl(a-

2o> 1iff(-(nt co+pon(nts (.g., (1*cational

int(-)(ntions, glc(+ic ta-g(ts,

lif(stl( c2ang(s, p2a-+acologicalag(nts cont-i0*t( to t2( -(1*ction of

co+plications. T2(-( a-( no clinical t-ial1ata a)aila0l( fo- t2( (ff(cts of glc(+ic

cont-ol in pati(nts >it2 a1)anc(1 co+plications,

t2( (l1(-l 95 (a-s of ag(, o-

o*ng c2il1-(n 7 (a-s of ag(. L(ss

st-ing(nt t-(at+(nt goals +a 0( app-op-iat(

fo- pati(nts >it2 li+it(1 lif( (=p(ctanci(s,

in t2( )(- o*ng o- ol1(- a1*lts,

an1 in in1i)i1*als >it2 co+o-0i1 con1itions.

S()(-( o- f-((- li+it of AC at >2ic2 f*-t2(- lo>(-ing

1o(s not -(1*c( t2( -is8 of co+plications,

at t2( -is8 of inc-(as(1

2poglc(+ia pa-tic*la-l in t2os( >it2

tp( 1ia0(t(s. 3o>()(-, t2( a0sol*t(

-is8s an1 0(n(fits of lo>(- ta-g(ts a-( *n8no>n.

T2( -is8s an1 0(n(fits of an AC

goal of 9K a-( c*--(ntl 0(ing t(st(1 inan ongoing st*1 ACCORD QAction to

Cont-ol Ca-1io)asc*la- Ris8 in Dia0(t(s

in tp( & 1ia0(t(s.

El()at(1 postc2all(ng( &/2 OGTT

gl*cos( )al*(s 2a)( 0((n associat(1 >it2

inc-(as(1 ca-1io)asc*la- -is8 in1(p(n1(ntof F#G in so+( (pi1(+iological

st*1i(s. #ostp-an1ial plas+a gl*cos(

##G l()(ls 4 +g$1l a-( *n*s*al in

non1ia0(tic in1i)i1*als, alt2o*g2 la-g(()(ning +(als can 0( follo>(1 0 plas+a

gl*cos( )al*(s *p to ' +g$1l. T2(-( a-(no> p2a-+acological ag(nts t2at p-i+a-il

+o1if ##G an1 t2(-(0 -(1*c( AC

in pa-all(l. T2*s, in in1i)i1*als >2o 2a)(

p-(+(al gl*cos( )al*(s >it2in ta-g(t 0*t

>2o a-( not +((ting AC ta-g(ts, consi1(-ation

of +onito-ing ##G @& 2 aft(- t2(

sta-t of t2( +(al an1 t-(at+(nt ai+(1 at

-(1*cing ##G )al*(s ' +g$1l +a

lo>(- AC. 3o>()(-, it s2o*l1 0( not(1

t2at t2( (ff(ct of t2(s( app-oac2(s on +ic-o/

o- +ac-o)asc*la- co+plications 2as

not 0((n st*1i(1 7&.

As -(ga-1s goals fo- glc(+ic cont-olfo- >o+(n >it2 GDM, -(co++(n1ations

f-o+ t2( Fo*-t2 Int(-national ?o-8s2op/Conf(-(nc( on G(stational Dia0(t(s s*gg(st

lo>(-ing +at(-nal capilla- 0loo1

gl*cos( conc(nt-ations to:5 +g$1l 5.7

++ol$l fasting, 4 +g$1l !.'

++ol$l at 2, an1$o- & +g$1l 9.!

++ol$l at & 2 aft(- t2( +(al 7&a. Fo-

f*-t2(- info-+ation on GDM, -(f(- to t2(

ADA position stat(+(nt 4. Fo- info-+ation

on glc(+ic cont-ol 1*-ing p-(gnanc

in >o+(n >it2 p-((=isting

1ia0(t(s, -(f(- to -(f. 77.

D. MNTR(co++(n1ations

#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)(

in1i)i1*ali6(1

MNT as n((1(1 to ac2i()(t-(at+(nt goals, p-(f(-a0l p-o)i1(1 0

a -(gist(-(1 1i(titian fa+ilia- >it2 t2(

co+pon(nts of 1ia0(t(s MNT. B

Bot2 t2( a+o*nt g-a+s of ca-0o21-at(

as >(ll as t2( tp( of ca-0o21-at(

in a foo1 infl*(nc( 0loo1 gl*cos( l()(l.

Monito-ing total g-a+s of ca-0o21-at(,

>2(t2(- 0 *s( of (=c2ang(s o-ca-0o21-at( co*nting, -(+ains a 8(

Table1'Correlation between A1C level and

mean plasma glucose levels on multiple testing

over 2! months "2!#

AC K

M(an plas+a gl*cos(+g$1l ++ol$l

9 75 !.5

! ! :.5

' &5 .5: &4 7.5

&!5 5.5 7 !.5

& 745 :.5

Position Statement


S##LEMENT , ANAR% &9 S

st-at(g in ac2i()ing glc(+ic cont-ol.

A

T2( *s( of t2( glc(+ic in1(=$glc(+ic


14/69

loa1 +a p-o)i1( an a11itional 0(n(fit

o)(- t2at o0s(-)(1 >2(n total ca-0o21-at(

is consi1(-(1 alon(. B

Lo>/ca-0o21-at( 1i(ts -(st-icting total

ca-0o21-at( to7 g$1a a-( not-(co++(n1(1 in t2( +anag(+(nt of

1ia0(t(s. E To -(1*c( t2( -is8 of n(p2-opat2, p-ot(in

inta8( s2o*l1 0( li+it(1 to t2( -(co++(n1(1

1i(ta- allo>anc( RDA

.' g$8g in t2os( >it2 an 1(g-(( of

CD. B

Sat*-at(1 fat inta8( s2o*l1 0( !K of

total calo-i(s. A

Inta8( of trans fat s2o*l1 0( +ini+i6(1.

E

?(ig2t loss is -(co++(n1(1 fo- all

o)(->(ig2t BMI &5. @&:.: 8g$+& o-

o0(s( BMI 7. 8g$+& a1*lts >2o2a)(, o- a-( at -is8 fo- 1()(loping, tp(

& 1ia0(t(s. E

T2( p-i+a- app-oac2 fo- ac2i()ing

>(ig2t loss is t2(-ap(*tic lif(stl(c2ang(, >2ic2 incl*1(s a -(1*ction in

(n(-g inta8( an1 an inc-(as( in p2sical

acti)it. A +o1(-at( 1(c-(as( in calo-ic

0alanc( 5 @, 8cal$1a >ill

-(s*lt in a slo> 0*t p-og-(ssi)( >(ig2t

loss @& l0$>((8. Fo- +ost pati(nts,

>(ig2t loss 1i(ts s2o*l1 s*ppl at l(ast

, @,& 8cal$1a fo- >o+(n an1,& @,9 8cal$1a fo- +(n. E

Initial p2sical acti)it -(co++(n1ations

s2o*l1 0( +o1(st an1 0as(1 on

t2( pati(ntPs >illingn(ss an1 a0ilit,

g-a1*all inc-(asing t2( 1*-ation an1

f-(((8 goal at

l(ast 5 +in$>((8. G-(at(- acti)it

l()(ls of at l(ast 2$1a of +o1(-at(

>al8ing o- 7 +in$1a of )igo-o*sJogging acti)it +a 0( n((1(1 to

ac2i()( s*cc(ssf*l long/t(-+ >(ig2tloss. E

D-*g t2(-ap fo- o0(sit an1 s*-g(- to

in1*c( >(ig2t loss +a 0( app-op-iat(

in s(l(ct(1 pati(nts. E

Nonn*t-iti)( s>((t(n(-s a-( saf( >2(n

cons*+(1 >it2in t2( acc(pta0l( 1ail

inta8( l()(ls (sta0lis2(1 0 t2( Foo1

an1 D-*g A1+inist-ation FDA. A

If a1*lts >it2 1ia0(t(s c2oos( to *s(

alco2ol, 1ail inta8( s2o*l1 0( li+it(1

to a +o1(-at( a+o*nt on( 1-in8 p(-

1a o- l(ss fo- a1*lt >o+(n an1 t>o

1-in8s p(- 1a o- l(ss fo- a1*lt +(non( 1-in8 is 1(fin(1 as & o6 0((-, 5 o6

>in(, o- .5 o6 1istill(1 spi-its. A Ro*tin( s*ppl(+(ntation >it2 antio=i1ants,

s*c2 as )ita+ins E an1 C an1

/ca-ot(n(, is not a1)is(1 0(ca*s( of

lac8 of ()i1(nc( of (fficac an1 conc(-n

-(lat(1 to long/t(-+ saf(t. A

B(n(fit f-o+ c2-o+i*+ s*ppl(+(ntation

in p(opl( >it2 1ia0(t(s o- o0(sit

2as not 0((n concl*si)(l 1(+onst-at(1

an1, t2(-(fo-(, cannot 0( -(co++(n1(1.

E

MNT is an int(g-al co+pon(nt of 1ia0(t(s

p-()(ntion, +anag(+(nt, an1 s(lf+anag(+(nt(1*cation. In a11ition to its

-ol( in p-()(nting an1 cont-olling 1ia0(t(s,

t2( ADA -(cogni6(s t2( i+po-tanc( of

n*t-ition as an (ss(ntial co+pon(nt of ano)(-all 2(alt2 lif(stl( . T2(s( g*i1(lin(s

a-( 0as(1 on p-incipl(s of goo1 n*t-ition

fo- t2( o)(-all pop*lation f-o+ t2( &5

Di(ta- G*i1(lin(s an1 t2( RDAs f-o+ t2(

Instit*t( of M(1icin( of t2( National

Aca1(+i(s of Sci(nc(s. A -()i(> of t2(

()i1(nc( an1 1(tail(1 info-+ation can 0(

fo*n1 in t2( && ADA t(c2nical -()i(>on t2is topic 75 an1 t2( &4 ADA

Stat(+(nts -(ga-1ing 1i(ta- ca-0o21-at(

79 an1 >(ig2t +anag(+(nt. 7!.

Goal of MNT t2at appli(s to in1i)i1*als

>it2 p-(/1ia0(t(s

D(c-(as( t2( -is8 of 1ia0(t(s an1 C"D0 p-o+oting p2sical acti)it an1

2(alt2 foo1 c2oic(s t2at -(s*lt in +o1(-at(

>(ig2t loss t2at is +aintain(1 o-,

at a +ini+*+, p-()(nts >(ig2t gain.Goal of MNT t2at appli(s to all in1i)i1*als

>it2 1ia0(t(s #-()(nt an1 t-(at t2( c2-onic co+plications

of 1ia0(t(s 0 attaining an1 +aintaining

opti+al +(ta0olic o*tco+(s,

incl*1ing 0loo1 gl*cos( an1 AC l()(l,

LDL an1 3DL c2ol(st(-ol an1 t-iglc(-i1(

l()(ls, 0loo1 p-(ss*-(, an1 0o1

>(ig2t Ta0l( 9.

Ac2i()ing n*t-ition/-(lat(1 goals -(


15/69

a coo-1inat(1 t(a+ (ffo-t t2at incl*1(s

t2( acti)( in)ol)(+(nt of t2( p(-son >it2

p-(/1ia0(t(s o- 1ia0(t(s. B(ca*s( of t2(

co+pl(=it of n*t-ition iss*(s, it is -(co++(n1(1

t2at a -(gist(-(1 1i(titian >2o is8no>l(1g(a0l( an1 s8ill(1 in i+pl(+(nting

n*t-ition t2(-ap into 1ia0(t(s +anag(+(ntan1 (1*cation 0( t2( t(a+

+(+0(- >2o p-o)i1(s MNT. 3o>()(-, it

is (ss(ntial t2at all t(a+ +(+0(-s a-(

8no>l(1g(a0l( a0o*t n*t-ition t2(-ap

an1 a-( s*ppo-ti)( of t2( p(-son >it2 1ia0(t(s

>2o n((1s to +a8( lif(stl(

c2ang(s.

MNT in)ol)(s a n*t-ition ass(ss+(nt

to ()al*at( t2( pati(ntPs foo1 inta8(, +(ta0olic

stat*s, lif(stl(, -(a1in(ss to +a8(

c2ang(s, goal s(tting, 1i(ta- inst-*ction,

an1 ()al*ation. To facilitat( a12(-(nc(,t2( plan s2o*l1 0( in1i)i1*ali6(1 an1

ta8( into acco*nt in1i)i1*al c*lt*-al, lif(stl(,

an1 financial consi1(-ations. Monito-ing

of gl*cos( an1 AC, lipi1s, 0loo1p-(ss*-(, an1 -(nal stat*s is (ss(ntial to

()al*at( n*t-ition/-(lat(1 o*tco+(s. If

goals a-( not +(t Ta0l( 9, c2ang(s +*st

0( +a1( in t2( o)(-all 1ia0(t(s ca-( an1

+anag(+(nt plan.

?(ig2t +anag(+(nt 7!

O)(->(ig2t an1 o0(sit a-( st-ongl

lin8(1 to t2( 1()(lop+(nt of tp( & 1ia0(t(san1 can co+plicat( its +anag(+(nt.

O0(sit is also an in1(p(n1(nt -is8 facto-

fo- 2p(-t(nsion an1 1slipi1(+ia as >(ll

as C"D, >2ic2 is t2( +aJo- ca*s( of 1(at2

in t2os( >it2 1ia0(t(s. Mo1(-at( >(ig2t

loss i+p-o)(s glc(+ic cont-ol, -(1*c(sC"D -is8, an1 can p-()(nt t2( 1()(lop+(nt

of tp( & 1ia0(t(s in t2os( >it2 p-(1ia0(t(s.

T2(-(fo-(, >(ig2t loss is an

i+po-tant t2(-ap(*tic st-at(g in all o)(->(ig2to- o0(s( in1i)i1*als >2o 2a)(

tp( & 1ia0(t(s o- a-( at -is8 fo- 1()(loping1ia0(t(s. T2( p-i+a- app-oac2 fo-

ac2i()ing >(ig2t loss, in t2( )ast +aJo-it

of cas(s, is t2(-ap(*tic lif(stl( c2ang(,

>2ic2 incl*1(s a -(1*ction in (n(-g inta8(

an1 an inc-(as( in p2sical acti)it. A

+o1(-at( 1(c-(as( in calo-ic 0alanc(

5 @, 8cal$1a >ill -(s*lt in a slo>

0*t p-og-(ssi)( >(ig2t loss @& l0$

>((8. Fo- +ost pati(nts, >(ig2t loss 1i(ts

s2o*l1 s*ppl at l(ast , @,&

8cal$1a fo- >o+(n an1 ,& @,9

8cal$1a fo- +(n.

In s(l(ct(1 pati(nts, 1-*g t2(-ap toac2i()( >(ig2t loss as an a1J*nct to lif(stl(

c2ang( +a 0( app-op-iat( 7'.3o>()(-, it is i+po-tant to not( t2at -(gain

of >(ig2t co++onl occ*-s on 1iscontin*ation

of +(1ication. In pati(nts

>it2 s()(-($+o-0i1 o0(sit, s*-gical options,

s*c2 as gast-ic 0pass an1 gast-oplast,

+a 0( app-op-iat( an1 allo>

significant i+p-o)(+(nt in glc(+ic cont-ol

>it2 -(1*ction o- 1iscontin*ation of

+(1ications 7:. It is i+po-tant to f*ll

()al*at( t2( pati(nt fo- (=isting o- -is8 fo-

C"D an1 i+p-o)( glc(+ic cont-ol p-(op(-ati)(l

in o-1(- to 1(c-(as( t2( -is8 ofco+plications. It is i+po-tant to co*ns(l

pati(nts on t2( -is8s of s*-g(-, incl*1ing

+o-talit, 1(p-(ssion, 2poglc(+ia, n*t-itional

1(fici(nci(s, ost(opo-osis, an1>(ig2t -(gain o)(- t2( long t(-+. "(-


S& DIABETES CARE, "OLME &:,


littl( 1ata a-( c*--(ntl a)aila0l( on t2(

long/t(-+ cons((ig2t loss in p(opl( >it2 1ia0(t(s. T2(

pot(ntial 0(n(fits s2o*l1 0( >(ig2(1against s2o-t/ an1 long/t(-+ -is8s 4.

#2sical acti)it is an i+po-tant co+pon(nt

of a co+p-(2(nsi)( >(ig2t+anag(+(nt

p-og-a+. R(g*la-

+o1(-at(/int(nsit p2sical acti)it (n2anc(s

long/t(-+ >(ig2t +aint(nanc(.R(g*la- acti)it also i+p-o)(s ins*lin

s(nsiti)it, glc(+ic cont-ol, an1 s(l(ct(1

-is8 facto-s fo- C"D i.(., 2p(-t(nsion

an1 1slipi1(+ia, an1 inc-(as(1 a(-o0icfitn(ss 1(c-(as(s t2( -is8 of co-ona- 2(a-t

1is(as( C3D. Initial p2sical acti)it-(co++(n1ations s2o*l1 0( +o1(st,

0as(1 on t2( pati(ntPs >illingn(ss an1

a0ilit, g-a1*all inc-(asing t2( 1*-ation

an1 f-(((8, >2(n

possi0l(. G-(at(- acti)it l()(ls of at l(ast

2$1a of +o1(-at( >al8ing o- 7 +in$

1a of )igo-o*s Jogging acti)it +a 0(


16/69

n((1(1 to ac2i()( s*cc(ssf*l long/t(-+

>(ig2t loss.

Di(ta- ca-0o21-at( 79

R(g*lation of 0loo1 gl*cos( to ac2i()(

n(a-/no-+al l()(ls is a p-i+a- goal in t2(+anag(+(nt of 1ia0(t(s, an1 t2*s, 1i(ta-

t(c2niing a +(al a-( i+po-tant in li+iting

t2( co+plications of 1ia0(t(s. Bot2 t2(

a+o*nt g-a+s an1 tp( of ca-0o21-at(

in a foo1 infl*(nc( 0loo1 gl*cos( l()(l.

T2( total a+o*nt of ca-0o21-at( cons*+(1

is a st-ong p-(1icto- of glc(+ic

-(spons(, an1 t2*s, +onito-ing total

g-a+s of ca-0o21-at(, >2(t2(- 0 *s( of

(=c2ang(s o- ca-0o21-at( co*nting, -(+ains

a 8( st-at(g in ac2i()ing glc(+ic

cont-ol. A -(c(nt analsis of t2( -an1o+i6(1

cont-oll(1 t-ials t2at 2a)( (=a+in(1t2( (fficac of t2( glc(+ic in1(= a +(as*-(

of t2( (ff(ct of tp( of ca-0o21-at(

on o)(-all 0loo1 gl*cos( cont-ol in1icat(s

t2at t2( *s( of t2is t(c2ni2(n total ca-0o21-at( is consi1(-(1

alon(.

Lo>/ca-0o21-at( 1i(ts a-( not -(co++(n1(1

in t2( +anag(+(nt of 1ia0(t(s.

Alt2o*g2 1i(ta- ca-0o21-at( is t2(

+aJo- cont-i0*to- to postp-an1ial gl*cos(

conc(nt-ation, it is an i+po-tant so*-c( of(n(-g, >at(-/sol*0l( )ita+ins an1 +in(-als,

an1 fi0(-. T2*s, in ag-((+(nt >it2

t2( National Aca1(+ of Sci(nc(s@Foo1

an1 N*t-ition Boa-1 4, a -(co++(n1(1

-ang( of ca-0o21-at( inta8( is

45@95K of total calo-i(s. In a11ition, 0(ca*s(t2( 0-ain an1 c(nt-al n(-)o*s sst(+

2a)( an a0sol*t( -(it2 1ia0(t(s.

T2( 1i(ta- -(f(-(nc( inta8( DRI/

acc(pta0l( +ac-on*t-i(nt 1ist-i0*tion

-ang( fo- p-ot(in is @75K of (n(-g inta8(

an1 t2( RDA is .' g 2ig2/t 1a 4.

Di(ta- inta8( of p-ot(in is si+ila- to

t2at of t2( g(n(-al p*0lic in in1i)i1*als>it2 1ia0(t(s an1 *s*all 1o(s not (=c((1

&K of (n(-g inta8(. Inta8( of p-ot(in int2is -ang( +a 0( a -is8 facto- fo- t2( 1()(lop+(nt

of 1ia0(tic n(p2-opat2 4&.

Bas(1 on st*1i(s in pati(nts >it2 )a-ing

stag(s of n(p2-opat2 4&@ 44, it s((+s

p-*1(nt to li+it p-ot(in inta8( in t2os(

>it2 1ia0(t(s to t2( RDA .' g$8g,

>2ic2 >o*l1 0( K of total calo-i(s.

Di(ta- fat

Sat*-at(1 an1 trans fatt aci1s a-( t2(

p-incipal 1i(ta- 1(t(-+inant of plas+a

LDL c2ol(st(-ol, t2( +aJo- -is8 facto- fo-

C"D. In non1ia0(tic in1i)i1*als, -(1*cingsat*-at(1 an1 trans fatt aci1s an1

c2ol(st(-ol inta8( 1(c-(as(s plas+a total

an1 LDL c2ol(st(-ol 0*t +a also -(1*c(

3DL c2ol(st(-ol. I+po-tantl, t2( -atio ofLDL to 3DL c2ol(st(-ol is not a1)(-s(l

aff(ct(1. St*1i(s in in1i)i1*als >it2 1ia0(t(s

1(+onst-ating t2( (ff(cts of sp(cific

p(-c(ntag(s of 1i(ta- sat*-at(1 an1 trans

fatt aci1s an1 sp(cific a+o*nts of 1i(ta-

c2ol(st(-ol on C"D -is8 a-( not a)aila0l(.

3o>()(-, t2os( >it2 1ia0(t(s a-( consi1(-(1

to 0( at si+ila- -is8 to t2os( >it2 apast 2isto- of C"D. T2(-(fo-(, 0(ca*s( of

a lac8 of sp(cific info-+ation, t2( goal fo-

1i(ta- fat inta8( a+o*nt an1 tp( fo-

in1i)i1*als >it2 1ia0(t(s is t2( sa+( as

fo- t2os( >it2o*t 1ia0(t(s >it2 a 2isto-

of C"D. T2( +ost -(c(nt g*i1(lin(s f-o+t2( National C2ol(st(-ol E1*cation #-og-a+

-(co++(n1 t2at total fat 0( &5@

75K of total calo-i(s an1 sat*-at(1 fat

!K 74. G*i1(lin(s f-o+ t2( A+(-ican3(a-t Association also -(co++(n1 t2at

sat*-at(1 fat 0(!K in t2os( >it2 1ia0(t(s,gi)(n t2(i- inc-(as(1 -is8 of C"D

45,49. Inta8( of trans fat s2o*l1 0(

+ini+i6(1.

Opti+al +ac-on*t-i(nt +i=

Fo- t2os( in1i)i1*als s((8ing g*i1anc(

-(ga-1ing +ac-on*t-i(nt 1ist-i0*tion, t2(

DRIs +a 0( 2(lpf*l T2( DRI -(po-t -(co++(n1s

t2at to +((t t2( 0o1Ps 1ail


17/69

n*t-itional n((1s >2il( +ini+i6ing -is8

fo- c2-onic 1is(as(s, a1*lts in g(n(-al,

not sp(cificall t2os( >it2 1ia0(t(s

s2o*l1 cons*+( 45@95K of total (n(-g

f-o+ ca-0o21-at(, &@75K f-o+ fat,an1 @75K f-o+ p-ot(in 4. Alt2o*g2

n*+(-o*s st*1i(s 2a)( att(+pt(1 toi1(ntif t2( opti+al co+0ination of +ac-on*t-i(nts

fo- t2os( >it2 1ia0(t(s, it is *nli8(l

t2at an on( s*c2 co+0ination of

+ac-on*t-i(nts (=ists. T2( 0(st +i= of

ca-0o21-at(,

p-ot(in, an1 fat app(a-s to )a-

1(p(n1ing on in1i)i1*al ci-c*+stanc(s.

Fi0(-

Si+ila- to t2( g(n(-al pop*lation, p(opl(

>it2 1ia0(t(s a-( (nco*-ag(1 to c2oos( a

)a-i(t of fi0(-/containing foo1s, s*c2 as

l(g*+(s, fi0(-/-ic2 c(-(als 5 g fi0(-$s(-)ing, as >(ll as f-*its, )(g(ta0l(s, an1

>2ol(/g-ain p-o1*cts 0(ca*s( t2( p-o)i1(

)ita+ins, +in(-als, fi0(-, an1 ot2(-

s*0stanc(s i+po-tant fo- goo1 2(alt2.R(1*c(1 calo-i( s>((tn(-s

R(1*c(1 calo-i( s>((t(n(-s app-o)(1 0

t2( FDA incl*1( s*ga- alco2ols (-t2-itol,

21-og(nat(1 sta-c2 21-olsat(s,

iso+alt, lactitol, +altitol, +annitol, so-0itol,

an1 =litol an1 tagatos(. St*1i(s *sing

s*0J(cts >it2 an1 >it2o*t 1ia0(t(s

2a)( s2o>n t2at s*ga- alco2ols p-o1*c( alo>(- postp-an1ial gl*cos( -(spons( t2an

s*c-os( o- gl*cos( an1 2a)( lo>(- a)aila0l(

(n(-g. S*ga- alco2ols contain, on

a)(-ag(, & calo-i(s$g-a+ on(/2alf t2(

calo-i(s of ot2(- s>((t(n(-s s*c2 as s*c-os(.

?it2 foo1s containing s*ga- alco2ols,s*0t-action of on(/2alf of s*ga-

alco2ol g-a+s f-o+ total ca-0o21-at(

g-a+s is app-op-iat(, pa-tic*la-l >2(n

*sing t2( ca-0o21-at( co*nting +(t2o1fo- +(al planning. T2(-( is no ()i1(nc(

t2at t2( a+o*nts of s*ga- alco2ol li8(l to0( cons*+(1 >ill -(s*lt in significant -(1*ction

in (n(-g inta8( o- long/t(-+ i+p-o)(+(nt

in glc(+ia. T2( *s( of s*ga-

alco2ols app(a-s to 0( saf(.

T2( FDA 2as app-o)(1 fi)( nonn*t-iti)(

s>((t(n(-s fo- *s( in t2( .S. ac(s*lfa+(

potassi*+, aspa-ta+(, n(ota+(,

sacc2a-in, an1 s*c-alos(. All 2a)( *n1(-gon(

-igo-o*s sc-*tin an1 2a)( 0((n

s2o>n to 0( saf( >2(n cons*+(1 0 t2(

p*0lic, incl*1ing p(opl( >it2 1ia0(t(s

an1 >o+(n >2o a-( p-(gnant.

Position Statement


S##LEMENT , ANAR% &9 S7Antio=i1ants

Sinc( 1ia0(t(s +a 0( a stat( of inc-(as(1

o=i1ati)( st-(ss, t2(-( 2as 0((n int(-(st in

p-(sc-i0ing antio=i1ant )ita+ins to in1i)i1*als

>it2 1ia0(t(s. ?2il( o0s(-)ational

st*1i(s 2a)( s2o>n a co--(lation

0(t>((n 1i(ta- o- s*ppl(+(ntal cons*+ption

of antio=i1ants an1 a )a-i(t of

clinical o*tco+(s s*c2 as p-()(ntion of

1is(as( stat(s 75,4!, la-g( plac(0ocont-oll(1

clinical t-ials 2a)( fail(1 to

s2o> a 0(n(fit an1, in so+( instanc(s,2a)( s*gg(st(1 a1)(-s( (ff(cts 75,4!.

C2-o+i*+

S()(-al s+all st*1i(s 2a)( s*gg(st(1 a

-ol( fo- c2-o+i*+ s*ppl(+(ntation int2( +anag(+(nt of gl*cos( intol(-anc(,

0o1 >(ig2t, GDM, an1 co-ticost(-oi1in1*c(1

1ia0(t(s 4' @5. Also, plac(0ocont-oll(1

st*1i(s con1*ct(1 in C2ina

fo*n1 t2at c2-o+i*+ s*ppl(+(ntation

2a1 0(n(ficial (ff(cts on glc(+ia, alt2o*g2

it is i+po-tant to not( t2at t2(

st*1 pop*lation in C2ina +a 2a)( 2a1+a-ginal 0as(lin( c2-o+i*+ stat*s. A -(c(nt

FDA stat(+(nt in1icat(1 t2at t2(-( is

ins*ffici(nt ()i1(nc( to s*ppo-t an of t2(

p-opos(1 2(alt2 clai+s fo- c2-o+i*+

s*ppl(+(ntation. T2( FDA concl*1(1

t2at alt2o*g2 a s+all st*1 s*gg(st(1 t2atc2-o+i*+ picolinat( +a -(1*c( t2( -is8

of ins*lin -(sistanc(, t2( (=ist(nc( of a -(lations2ip

0(t>((n c2-o+i*+ picolinat(

an1 (it2(- ins*lin -(sistanc( o- tp( & 1ia0(t(s>as 2ig2l *nc(-tain s(( c2-o+i*+

picolinat( an1 ins*lin -(sistanc( at>>>.cfsan.f1a.go)$1+s$(ig2t 5.

Alco2ol

Fo- in1i)i1*als >it2 1ia0(t(s, t2( sa+(

p-(ca*tions appl -(ga-1ing t2( *s( of alco2ol


18/69

t2at appl to t2( g(n(-al pop*lation.

If in1i)i1*als c2oos( to *s( alco2ol,

alco2ol/containing 0()(-ag(s s2o*l1 0(

li+it(1 to a +o1(-at( a+o*nt l(ss t2an

on( 1-in8 p(- 1a fo- a1*lt >o+(n an1l(ss t2an t>o 1-in8s p(- 1a fo- a1*lt +(n.

On( alco2ol containing 0()(-ag( is 1(fin(1as & o6 0((-, 5 o6 >in(, o- .5 o6 1istill(1

spi-its. Eac2 contains 5 g alco2ol.

E. DSME

R(co++(n1ations

#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)(

DSME acco-1ing to national stan1a-1s

>2(n t2(i- 1ia0(t(s is 1iagnos(1 an1 as

n((1(1 t2(-(aft(-. B

DSME s2o*l1 0( p-o)i1(1 0 2(alt2

ca-( p-o)i1(-s >2o a-( (ll/0(ing is

st-ongl associat(1 >it2 positi)( 1ia0(t(so*tco+(s. C

DSME s2o*l1 0( -(i+0*-s(1 0 t2i-1pa-t

pao-s. E

DSME is an (ss(ntial (l(+(nt of 1ia0(t(s

ca-( 5&@5', an1 National Stan1a-1s fo-

DSME a-( 0as(1 on ()i1(nc( fo- its 0(n(fits.

E1*cation 2(lps p(opl( >it2 1ia0(t(s

initiat( (ff(cti)( s(lf/ca-( >2(n t2(a-( fi-st 1iagnos(1. Ongoing DSME also

2(lps p(opl( >it2 1ia0(t(s +aintain (ff(cti)(

s(lf/+anag(+(nt as t2(i- 1ia0(t(s

p-(s(nts n(> c2all(ng(s an1 t-(at+(nt

a1)anc(s 0(co+( a)aila0l(. DSME 2(lps

pati(nts opti+i6( +(ta0olic cont-ol, p-()(ntan1 +anag( co+plications, an1

+a=i+i6( it2 DSME foc*singon p-o)i1ing info-+ation to a

s8ill/0as(1 app-oac2 t2at foc*s(s on

2(lping t2os( >it2 1ia0(t(s +a8( info-+(1

s(lf/+anag(+(nt c2oic(s. S()(-al

st*1i(s 2a)( fo*n1 t2at DSME is associat(1

>it2 i+p-o)(1 1ia0(t(s 8no>l(1g(

57, i+p-o)(1 s(lf/ca-( 0(2a)io- 57,

i+p-o)(1 clinical o*tco+(s s*c2 as lo>(-

AC 54,55,5!,5', lo>(- s(lf/-(po-t(1

>(ig2t 57, an1 i+p-o)(1 (-( -(po-t(1 fo-

DSME t2at >(-( long(- an1 incl*1(1 follo>/

*p s*ppo-t 57, >(-( tailo-(1 to in1i)i1*aln((1s an1 p-(f(-(nc(s 5&, an1

a11-(ss(1 psc2osocial iss*(s 5&,57,5!.

T2( national stan1a-1s fo- DSME

ADA/-(cogni6(1 DSME p-og-a+s 2a)(

staff t2at incl*1(s at l(ast a -(gist(-(1

n*-s( an1 a -(gist(-(1 1i(titian t2(s( staff

+*st 0( c(-tifi(1 1ia0(t(s (1*cato-s o-

2a)( -(c(nt (=p(-i(nc( in 1ia0(t(s (1*cation

an1 +anag(+(nt. T2( c*--ic*l*+ of

ADA/-(cogni6(1 DSME p-og-a+s +*st

co)(- all a-(as of 1ia0(t(s +anag(+(nt,

>it2 t2( ass(ss(1 n((1s of t2( in1i)i1*al

1(t(-+ining >2ic2 a-(as a-( a11-(ss(1.All ADA/-(cogni6(1 DSME p-og-a+s *tili6(

a p-oc(ss of contin*o*s >>.2cfa.go)$co)(-ag(.

F. #2sical acti)it

R(co++(n1ations To i+p-o)( glc(+ic cont-ol, assist

>it2 >(ig2t +aint(nanc(, an1 -(1*c(

-is8 of C"D, at l(ast 5 +in$>((8 of

+o1(-at(/int(nsit a(-o0ic p2sical acti)it

5@!K of +a=i+*+ 2(a-t -at(

is -(co++(n1(1 an1$o- at l(ast : +in$>((8 of )igo-o*s a(-o0ic (=(-cis(

!K of +a=i+*+ 2(a-t -at(. T2(

p2sical acti)it s2o*l1 0( 1ist-i0*t(1

o)(- at l(ast 7 1as$>((8 an1 >it2 no+o-( t2an & cons(c*ti)( 1as >it2o*t

p2sical acti)it. A In t2( a0s(nc( of cont-ain1ications,

p(opl( >it2 tp( & 1ia0(t(s s2o*l1 0(

(nco*-ag(1 to p(-fo-+ -(sistanc( (=(-cis(

t2-(( ti+(s a >((8, ta-g(ting all

+aJo- +*scl( g-o*ps, p-og-(ssing to

t2-(( s(ts of ' @ -(p(titions at a

>(ig2t t2at cannot 0( lift(1 +o-( t2an

'@ ti+(s. A


19/69

In1ications fo- g-a1(1 (=(-cis( t(st

>it2 (l(ct-oca-1iog-a+ +onito-ing

A g-a1(1 (=(-cis( t(st >it2 (l(ct-oca-1iog-a+

ECG +onito-ing s2o*l1 0(

s(-io*sl consi1(-(1 0(fo-( *n1(-ta8inga(-o0ic p2sical acti)it >it2 int(nsit

(=c((1ing t2( 1(+an1s of ()(-1ali)ing +o-( int(ns( t2an 0-is8 >al8ing

in p-()io*sl s(1(nta- 1ia0(tic in1i)i1*als

>2os( /(a- -is8 of a

co-ona- ()(nt is li8(l to 0( K.

ADA t(c2nical -()i(>s on (=(-cis( in pati(nts

>it2 1ia0(t(s 2a)( s*++a-i6(1 t2(

)al*( of (=(-cis( in t2( 1ia0(t(s +anag(+(nt

plan 5:,9. R(g*la- (=(-cis( 2as

0((n s2o>n to i+p-o)( 0loo1 gl*cos(

cont-ol, -(1*c( ca-1io)asc*la- -is8 facto-s,

cont-i0*t( to >(ig2t loss, an1 i+p-o)(

>(ll/0(ing. F*-t2(-+o-(, -(g*la-(=(-cis( +a p-()(nt tp( & 1ia0(t(s in

2ig2/-is8 in1i)i1*als ' @.

D(finitions

T2( follo>ing 1(finitions a-( 0as(1 ont2os( o*tlin(1 in #2sical Acti)it an1

3(alt2, t2( ::9 -(po-t of t2( S*-g(on

G(n(-al 9. #2sical acti)it is 1(fin(1




as 0o1il +o)(+(nt p-o1*c(1 0 t2(

cont-action of s8(l(tal +*scl( t2at -(al8ing,0iccling, Jogging, s>i++ing, >at(- a(-o0ics,

an1 +an spo-ts. R(sistanc( (=(-cis(consists of acti)iti(s t2at *s(

+*sc*last-(ngt2 to +o)( a >(ig2t o-

>o-8 against a -(sisti)( loa1. E=a+pl(s

incl*1( >(ig2t lifting an1 (=(-cis(s *sing

>(ig2t +ac2in(s.

Eff(cts of st-*ct*-(1 (=(-cis(

int(-)(ntions on glc(+ic cont-ol

an1 0o1 >(ig2t in tp( & 1ia0(t(s

Bo*l(W (t al. 9& *n1(-too8 a sst(+atic

-()i(> an1 +(ta/analsis on t2( (ff(cts of

st-*ct*-(1 (=(-cis( int(-)(ntions in clinical

t-ials of 1*-ation ' >((8s on 30Ac

an1 0o1 +ass in p(opl( >it2 tp( & 1ia0(t(s.T>(l)( a(-o0ic t-aining st*1i(s

an1 t>o -(sistanc( t-aining st*1i(s >(-(incl*1(1 totaling 54 s*0J(cts, an1 t2(

-(s*lts >(-( pool(1 *sing stan1a-1 +(taanaltic

statistical +(t2o1s. #ostint(-)(ntion

30Ac >as significantl lo>(- in

(=(-cis( t2an cont-ol g-o*ps. M(ta-(g-(ssion

confi-+(1 t2at t2( 0(n(ficial (ff(ct of

(=(-cis( on 30Ac >as in1(p(n1(nt of

an (ff(ct on 0o1 >(ig2t. T2(-(fo-(,

st-*ct*-(1 (=(-cis( p-og-a+s 2a1 a statisticall

an1 clinicall significant 0(n(ficial

(ff(ct on glc(+ic cont-ol, an1 t2is (ff(ct

>as not +(1iat(1 p-i+a-il 0 >(ig2tloss.

Bo*l(W (t al. 97 lat(- *n1(-too8 a

+(ta/analsis of t2( int(--(lations2ips

a+ong (=(-cis( int(nsit, (=(-cis( )ol*+(,c2ang( in ca-1io-(spi-ato- fitn(ss,

an1 c2ang( in 30Ac. T2is +(ta/analsis

p-o)i1(s s*ppo-t fo- 2ig2(-/int(nsit a(-o0ic

(=(-cis( in p(opl( >it2 tp( & 1ia0(t(s

as a +(ans of i+p-o)ing 30Ac. T2(s(

-(s*lts >o*l1 p-o)i1( s*ppo-t fo- (nco*-aging

tp( & 1ia0(tic in1i)i1*als >2o

a-( al-(a1 (=(-cising at +o1(-at( int(nsitto consi1(- inc-(asing t2( int(nsit of

t2(i- (=(-cis( in o-1(- to o0tain a11itional

0(n(fits in 0ot2 a(-o0ic fitn(ss an1 glc(+ic

cont-ol.

F-(((8.

T2( A+(-ican Coll(g( of Spo-ts M(1icin(no> -(co++(n1s -(sistanc( t-aining 0(

incl*1(1 in fitn(ss p-og-a+s fo- a1*lts>it2 tp( & 1ia0(t(s 94. R(sistanc( (=(-cis(

i+p-o)(s ins*lin s(nsiti)it to

a0o*t t2( sa+( (=t(nt as a(-o0ic (=(-cis(

95. T>o clinical t-ials p*0lis2(1 in &&

p-o)i1(1 st-ong ()i1(nc( fo- t2( )al*( of

-(sistanc( t-aining in tp( & 1ia0(t(s

99,9!.

E)al*ation of t2( 1ia0(tic pati(nt


20/69

0(fo-( -(co++(n1ing an (=(-cis(

p-og-a+

B(fo-( 0(ginning a p-og-a+ of p2sical

acti)it +o-( )igo-o*s t2an 0-is8 >al8ing,

p(opl( >it2 1ia0(t(s s2o*l1 0( ass(ss(1fo- con1itions t2at +ig2t 0(

associat(1 >it2 inc-(as(1 li8(li2oo1 ofC"D o- t2at +ig2t cont-ain1icat( c(-tain

tp(s of (=(-cis( o- p-(1ispos( to inJ*-,

s*c2 as *ncont-oll(1 2p(-t(nsion, s()(-(

a*tono+ic n(*-opat2, s()(-( p(-ip2(-al

n(*-opat2, an1 p-(p-olif(-ati)(

o- p-olif(-ati)( -(tinopat2 o- +ac*la-

(1(+a. T2( pati(ntPs ag( an1 p-()io*s

p2sical acti)it l()(l s2o*l1 0( consi1(-(1.

A -(c(nt sst(+atic -()i(> fo- t2(

.S. #-()(nti)( S(-)ic(s Tas8 Fo-c( ca+(

to t2( concl*sion t2at st-(ss t(sts s2o*l1

*s*all not 0( -(co++(n1(1 to 1(t(ctisc2(+ia in as+pto+atic in1i)i1*als at

lo> CAD -is8 K -is8 of a ca-1iac

()(nt o)(- (a-s 0(ca*s( t2( -is8s of

s*0s((ig2(1 t2( (=p(ct(1

0(n(fits f-o+ 1(t(ction of p-()io*sl

*ns*sp(ct(1 isc2(+ia 9',9:

E=(-cis( in t2( p-(s(nc( of

nonopti+al glc(+ic cont-ol

3er/lceia. ?2(n p(opl( >it2 tp(

1ia0(t(s a-( 1(p-i)(1 of ins*lin fo-

&@4' 2 an1 8(totic, (=(-cis( can >o-s(n2p(-glc(+ia an1 8(tosis !. "igo-o*s

acti)it s2o*l1 p-o0a0l 0( a)oi1(1 in t2(

p-(s(nc( of 8(tosis. T2(-(fo-(, p-o)i1(1

t2( pati(nt f((ls >(ll an1 *-in( an1$o-

0loo1 8(ton(s a-( n(gati)(, it is not n(c(ssa-

to postpon( (=(-cis( 0as(1 si+plon 2p(-glc(+ia.

3o/lceia. In in1i)i1*als ta8ing ins*lin

an1$o- ins*lin s(c-(tagog*(s, p2sical

acti)it can ca*s( 2poglc(+ia if+(1ication 1os( o- ca-0o21-at( cons*+ption

is not alt(-(1. 3poglc(+ia>o*l1 0( -a-( in 1ia0(tic in1i)i1*als >2o

a-( not t-(at(1 >it2 ins*lin o- ins*lin

s(c-(tagog*(s. A11(1 ca-0o21-at(

s2o*l1 0( ing(st(1 if p-(/(=(-cis( gl*cos(

l()(ls a-( +g$1l 5.9 ++ol$l !.

?( ag-(( >it2 t2is -(co++(n1ation fo-

in1i)i1*als on ins*lin an1$o- an ins*lin

s(c-(tagog*(. 3o>()(-, t2( -()is(1

g*i1(lin(s cla-if t2at s*ppl(+(nta- ca-0o21-at(

is g(n(-all not n(c(ssa- fo-

in1i)i1*als t-(at(1 onl >it2 1i(t, +(tfo-+in,

/gl*cosi1as( in2i0ito-s an1$o-

THDs >it2o*t ins*lin o- a s(c-(tagog*(!&.

E=(-cis( in t2( p-(s(nc( of sp(cificlong/t(-+ co+plications of 1ia0(t(s

Retino3at4. In t2( p-(s(nc( of p-olif(-ati)(

1ia0(tic -(tinopat2 #DR o- s()(-(

nonp-olif(-ati)( 1ia0(tic -(tinopat2

N#DR, )igo-o*s a(-o0ic o- -(sistanc(

(=(-cis( +a 0( cont-ain1icat(1 0(ca*s(

of t2( -is8 of t-igg(-ing )it-(o*s 2(+o--2ag(

o- -(tinal 1(tac2+(nt !7.

%eri34eral ne5ro3at4. D(c-(as(1 pain

s(nsation in t2( (=t-(+iti(s >o*l1 -(s*lt

in inc-(as(1 -is8 of s8in 0-(a81o>n an1

inf(ction an1 of C2a-cot Joint 1(st-*ction.T2(-(fo-(, in t2( p-(s(nc( of s()(-(

p(-ip2(-al n(*-opat2, it +a 0( 0(st to

(nco*-ag( non@>(ig2t/0(a-ing acti)iti(s

s*c2 as s>i++ing, 0iccling, o- a-+ (=(-cis(s!4,!5.

A5tonoic ne5ro3at4. A*tono+ic

n(*-opat2 can inc-(as( t2( -is8 of (=(-cis(/

in1*c(1 inJ*- 0 1(c-(asing ca-1iac

-(sponsi)(n(ss to (=(-cis(, post*-al 2pot(nsion,

i+pai-(1 t2(-+o-(g*lation

1*( to i+pai-(1 s8in 0loo1 flo> an1

s>(ating, i+pai-(1 nig2t )ision 1*( toi+pai-(1 papilla- -(action, i+pai-(1

t2i-st inc-(asing -is8 of 1(21-ation, an1

gast-opa-(sis >it2 *np-(1icta0l( foo1 1(li)(-

!4. A*tono+ic n(*-opat2 is also

st-ongl associat(1 >it2 C"D in p(opl(

>it2 1ia0(t(s !9,!!. #(opl( >it2 1ia0(tica*tono+ic n(*-opat2 s2o*l1 1(finit(l

*n1(-go ca-1iac in)(stigation

0(fo-( 0(ginning p2sical acti)it +o-(

int(ns( t2an t2( a-( acc*sto+(1 to.

Microalb5in5ria and ne34ro3at4.

#2sical acti)it can ac*t(l inc-(as( *-ina-p-ot(in (=c-(tion. T2(-( is no ()i1(nc(

f-o+ clinical t-ials o- co2o-t st*1i(s

1(+onst-ating t2at )igo-o*s (=(-cis( inc-(as(s

t2( -at( of p-og-(ssion of 1ia0(tic

8i1n( 1is(as(. T2(-( +a 0( no n((1 fo-

an sp(cific (=(-cis( -(st-ictions fo- p(opl(

>it2 1ia0(tic 8i1n( 1is(as( !'.

G. #sc2osocial ass(ss+(nt an1 ca-(


21/69

R(co++(n1ations

#-(li+ina- ass(ss+(nt of psc2ological

an1 social stat*s s2o*l1 0( incl*1(1

Position Statement

DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S5

as pa-t of t2( +(1ical +anag(+(nt of1ia0(t(s. E

#sc2osocial sc-((ning s2o*l1 incl*1(

0*t is not li+it(1 to attit*1(s a0o*t t2(

illn(ss, (=p(ctations fo- +(1ical +anag(+(nt

an1 o*tco+(s, aff(ct$+oo1,

g(n(-al an1 1ia0(t(s/-(lat(1 2(n a12(-(nc( to t2( +(1ical -(gi+(nis poo-. E

It is p-(f(-a0l( to inco-po-at( psc2ological

t-(at+(nt into -o*tin( ca-(

-at2(- t2an >ait fo- i1(ntification of asp(cific p-o0l(+ o- 1(t(-io-ation in

psc2ological stat*s. E

#sc2ological an1 social stat( can i+pact

t2( pati(ntPs a0ilit to ca-- o*t 1ia0(t(s

ca-( tas8s !:@'4. As a -(s*lt, 2(alt2 stat*s

+a 0( co+p-o+is(1. Fa+il conflict

a-o*n1 1ia0(t(s ca-( tas8s is also co++on

an1 +a int(-f(-( >it2 t-(at+(nto*tco+(s '5. T2(-( a-( oppo-t*niti(s

fo- t2( clinician to ass(ss psc2osocial stat*s

in a ti+(l an1 (ffici(nt +ann(- so

t2at -(f(--al fo- app-op-iat( s(-)ic(s can

0( acco+plis2(1 '9.

( oppo-t*niti(s fo- sc-((ning ofpsc2osocial stat*s occ*- at 1iagnosis,

1*-ing -(g*la-l sc2(1*l(1 +anag(+(nt

)isits, 1*-ing 2ospitali6ations, at 1isco)(-

of co+plications, o- at t2( 1isc-(tionof t2( clinician >2(n p-o0l(+s in gl*cos(

cont-ol, it2

+(1ical -(gi+(n 1*( to s(lf o- ot2(-s

!:,'', 1(p-(ssion >it2 t2( possi0ilit of

s(lf/2a-+ ',', in1ications of an (ating

1iso-1(- ': o- a p-o0l(+ t2at app(a-s

to 0( o-ganic in o-igin, an1

cogniti)( f*nctioning t2at significantl

i+pai-s J*1g+(nt '. In t2(s( cas(s, i++(1iat(

-(f(--al fo- f*-t2(- ()al*ation 0

a +(ntal 2(alt2 sp(cialist fa+ilia- >it2 1ia0(t(s

+anag(+(nt s2o*l1 occ*-. B(2a)io-al

ass(ss+(nt of +anag(+(nt s8ills isalso -(co++(n1(1.

It is p-(f(-a0l( to inco-po-at( psc2ological

t-(at+(nt into -o*tin( ca-( -at2(-

t2an >aiting fo- i1(ntification of a sp(cificp-o0l(+ o- 1(t(-io-ation in psc2ological

stat*s '9. Sc-((ning tools can facilitat(

t2is goal, an1 alt2o*g2 t2( clinician +a

not f((l ill acc(pt -(f(--al fo- ot2(-s(-)ic(s. It is i+po-tant to (sta0lis2 t2at

(+otional >(ll/0(ing is pa-t of 1ia0(t(s

+anag(+(nt '!.

3. R(f(--al fo- 1ia0(t(s +anag(+(nt

Fo- a )a-i(t of -(asons, so+( p(opl( >it2

1ia0(t(s an1 t2(i- 2(alt2 ca-( p-o)i1(-s1o not ac2i()( t2( 1(si-(1 goals of t-(at+(nt

Ta0l( 9. Int(nsification of t2(

t-(at+(nt -(gi+(n is s*gg(st(1 an1 incl*1(s

i1(ntification o- ass(ss+(nt of0a--i(-s to a12(-(nc(, c*lt*-all app-op-iat(

an1 (n2anc(1 DSME, co+anag(+(nt>it2 a 1ia0(t(s t(a+, c2ang( in

p2a-+acological t2(-ap, initiation of o-

inc-(as( in SMBG, +o-( f-(it2 t2( pati(nt, an1 -(f(--al to an (n1oc-inologist.

I. Int(-c*--(nt illn(ss

T2( st-(ss of illn(ss, t-a*+a, an1$o- s*-g(-

f-(


22/69

8(toaci1osis DA o- non8(totic 2p(-os+ola-

stat(. An con1ition l(a1ing to

1(t(-io-ation in glc(+ic cont-ol n(c(ssitat(s

+o-( f-((-ing ag(nts o-

MNT alon( +a t(+po-a-il -(it2o*t 1ia0(t(s. T2( 2ospitali6(1

pati(nt s2o*l1 0( t-(at(1 0 a p2sician>it2 (=p(-tis( in t2( +anag(+(nt of 1ia0(t(s,

an1 -(c(nt st*1i(s s*gg(st t2at

ac2i()ing )(- st-ing(nt glc(+ic cont-ol

+a -(1*c( +o-talit in t2( i++(1iat(

post+oca-1ial infa-ction p(-io1 :.

Agg-(ssi)( glc(+ic +anag(+(nt >it2

ins*lin +a -(1*c( +o-0i1it in pati(nts

>it2 s()(-( ac*t( illn(ss :&.Fo- f*-t2(- info-+ation on +anag(+(nt

of pati(nts in t2( 2ospital >it2 DA

o- non8(totic 2p(-os+ola- stat(, -(f(- to

t2( ADA position stat(+(nt :.

. 3poglc(+ia

R(co++(n1ations Gl*cos( 5@& g is t2( p-(f(--(1

t-(at+(nt fo- 2poglc(+ia, alt2o*g2

an fo-+ of ca-0o21-at( t2at contains

gl*cos( +a 0( *s(1, an1 t-(at+(nt (ff(ctss2o*l1 0( appa-(nt in 5 +in. E

T-(at+(nt (ff(cts on 2poglc(+ia+a onl 0( t(+po-a-il co--(ct(1.

T2(-(fo-(, plas+a gl*cos( s2o*l1 0(

t(st(1 again in 5 +in as a11itional

t-(at+(nt +a 0( n(c(ssa-. B

Gl*cagon s2o*l1 0( p-(sc-i0(1 fo- all

pati(nts at significant -is8 of s()(-( 2poglc(+ia

an1 1o(s not -(it2 t2(

ca-0o21-at( cont(nt of t2( foo1. Alt2o*g2

p*-( gl*cos( +a 0( t2( p-(f(--(1

t-(at+(nt, an fo-+ of ca-0o21-at( t2at

contains gl*cos( >ill -ais( 0loo1 gl*cos(.

A11ing p-ot(in to ca-0o21-at( 1o(s not

aff(ct t2( glc(+ic -(spons( an1 1o(s not

p-()(nt s*0s(()(-, +a -(ta-1 an1 t2(n

p-olong t2( ac*t( glc(+ic -(spons( :4.Ra-( sit*ations of s()(-( 2poglc(+ia

>2(-( t2( in1i)i1*al -(it2 o-al ca-0o21-at( s2o*l1 0(t-(at(1 *sing (+(-g(nc gl*cagon 8its,

>2ic2 -(it2, o- 2a)ing c*sto1ial

ca-( of, p(opl( >it2 1ia0(t(s, s*c2 as fa+il

+(+0(-s, -oo++at(s, sc2ool p(-sonn(l,

c2il1 ca-( p-o)i1(-s, co--(ctional

instit*tion staff, an1 co>o-8(-s, s2o*l1

0( inst-*ct(1 in *s( of s*c2 8its. An in1i)i1*al1o(s not n((1 to 0( a 2(alt2 ca-(




p-of(ssional to saf(l a1+inist(- gl*cagon.

Ca-( s2o*l1 0( ta8(n to (ns*-( t2at*n(=pi-(1 gl*cagon 8its a-( a)aila0l(.

. I++*ni6ation

R(co++(n1ations

Ann*all p-o)i1( an infl*(n6a )accin(to all 1ia0(tic pati(nts 9 +ont2s of

ag(. C #-o)i1( at l(ast on( lif(ti+( pn(*+ococcal

)accin( fo- a1*lts >it2 1ia0(t(s.

A on(/ti+( -()accination is -(co++(n1(1

fo- in1i)i1*als 94 (a-s of

ag( p-()io*sl i++*ni6(1 >2(n t2(

>(-(95 (a-s of ag( if t2( )accin( >as

a1+inist(-(15 (a-s ago. Ot2(- in1ications

fo- -(p(at )accination incl*1(


23/69

n(p2-otic sn1-o+(, c2-onic -(nal 1is(as(,

an1 ot2(- i++*noco+p-o+is(1

stat(s, s*c2 as aft(- t-ansplantation. C

Infl*(n6a an1 pn(*+onia a-( co++on,

p-()(nta0l( inf(ctio*s 1is(as(s associat(1>it2 2ig2 +o-talit an1 +o-0i1it in t2(

(l1(-l an1 in p(opl( >it2 c2-onic 1is(as(s.T2(-( a-( li+it(1 st*1i(s -(po-ting

t2( +o-0i1it an1 +o-talit of infl*(n6a

an1 pn(*+ococcal pn(*+onia sp(cificall

in p(opl( >it2 1ia0(t(s. O0s(-)ational

st*1i(s of pati(nts >it2 a )a-i(t of

c2-onic illn(ss(s, incl*1ing 1ia0(t(s,

s2o> t2at t2(s( con1itions a-( associat(1

>it2 an inc-(as( in 2ospitali6ations fo- infl*(n6a

an1 its co+plications. Bas(1 on a

cas(/cont-ol s(-i(s, infl*(n6a )accin( 2as

0((n s2o>n to -(1*c( 1ia0(t(s/-(lat(1

2ospital a1+ission 0 as +*c2 as !:K1*-ing fl* (pi1(+ics :5. #(opl( >it2 1ia0(t(s

+a 0( at inc-(as(1 -is8 of t2( 0act(-(+ic

fo-+ of pn(*+ococcal inf(ction

an1 2a)( 0((n -(po-t(1 to 2a)( a 2ig2 -is8of nosoco+ial 0act(-(+ia, >2ic2 2as a

+o-talit -at( as 2ig2 as 5K.

Saf( an1 (ff(cti)( )accin(s a-( a)aila0l(

t2at can g-(atl -(1*c( t2( -is8 of

s(-io*s co+plications f-o+ t2(s( 1is(as(s

:9,:!. T2(-( is s*ffici(nt ()i1(nc( to

s*ppo-t t2at p(opl( >it2 1ia0(t(s 2a)(

app-op-iat( s(-ologic an1 clinical -(spons(sto t2(s( )accinations. T2( C(nt(-s

fo- Dis(as( Cont-olPs A1)iso-

Co++itt(( on I++*ni6ation #-actic(s

-(co++(n1s infl*(n6a an1 pn(*+ococcal

)accin(s fo- all in1i)i1*als 95 (a-s

of ag(, as >(ll as fo- all in1i)i1*als of anag( >it2 1ia0(t(s.

Fo- a co+pl(t( 1isc*ssion on t2( p-()(ntion

of infl*(n6a an1 pn(*+ococcal

1is(as( in p(opl( >it2 1ia0(t(s, cons*ltt2( t(c2nical -()i(> an1 position stat(+(nt

on t2is s*0J(ct :',::.*I. %RE*ENTION AND

MANA"EMENT O!

DIABETES COM%ICATIONS

A. C"D

C"D is t2( +aJo- ca*s( of +o-talit fo-

in1i)i1*als >it2 1ia0(t(s. It is also a +aJo-

cont-i0*to- to +o-0i1it an1 1i-(ct

an1 in1i-(ct costs of 1ia0(t(s. Tp( & 1ia0(t(s

is an in1(p(n1(nt -is8 facto- fo-

+ac-o)asc*la- 1is(as(, an1 its co++on

co(=isting con1itions (.g., 2p(-t(nsion

an1 1slipi1(+ia a-( also -is8 facto-s.

St*1i(s 2a)( s2o>n t2( (fficac of -(1*cingca-1io)asc*la- -is8 facto-s in p-()(nting

o- slo>ing C"D. E)i1(nc( iss*++a-i6(1 in t2( follo>ing s(ctions an1

-()i(>(1 in 1(tail in t2( ADA t(c2nical

-()i(>s on 2p(-t(nsion , 1slipi1(+ia

, aspi-in t2(-ap &, an1

s+o8ing c(ssation 7 an1 t2( cons(ns*s

stat(+(nt on C3D in p(opl( >it2 1ia0(t(s

4. E+p2asis s2o*l1 0( plac(1

on -(1*cing ca-1io)asc*la- -is8 facto-s,

>2(n possi0l(, an1 clinicians s2o*l1 0(

al(-t fo- signs an1 s+pto+s of at2(-oscl(-osis.

. 3p(-t(nsion$0loo1 p-(ss*-(

cont-olR(co++(n1ations

Sc-((ning an1 1iagnosis

Bloo1 p-(ss*-( s2o*l1 0( +(as*-(1 at

()(- -o*tin( 1ia0(t(s )isit. #ati(ntsfo*n1 to 2a)( sstolic 0loo1 p-(ss*-(

7 ++3g o- 1iastolic 0loo1 p-(ss*-(

' ++3g s2o*l1 2a)( 0loo1

p-(ss*-( confi-+(1 on a s(pa-at( 1a.

C

Goals

#ati(nts >it2 1ia0(t(s s2o*l1 0( t-(at(1

to a sstolic 0loo1 p-(ss*-( 7++3g. C

#ati(nts >it2 1ia0(t(s s2o*l1 0( t-(at(1

to a 1iastolic 0loo1 p-(ss*-( '

++3g. B

T-(at+(nt

#ati(nts >it2 2p(-t(nsion sstolic0loo1 p-(ss*-(4 o- 1iastolic 0loo1

p-(ss*-( : ++3g s2o*l1 -(c(i)(

1-*g t2(-ap in a11ition to lif(stl( an1

0(2a)io-al t2(-ap. A M*ltipl( 1-*g t2(-ap t>o o- +o-(

ag(nts at p-op(- 1os(s is g(n(-all -(it2 a sstolic 0loo1 p-(ss*-(

of 7@7: ++3g o- a 1iastolic 0loo1

p-(ss*-( of '@': ++3g s2o*l1 0(

gi)(n lif(stl( an1 0(2a)io-al t2(-ap

alon( fo- a +a=i+*+ of 7 +ont2s an1

t2(n, if ta-g(ts a-( not ac2i()(1, in a11ition,


24/69

0( t-(at(1 >it2 p2a-+acological

ag(nts t2at 0loc8 t2( -(nin/angiot(nsin

sst(+. E

Initial 1-*g t2(-ap fo- t2os( >it2 a

0loo1 p-(ss*-( 4$: ++3gs2o*l1 0( >it2 a 1-*g class 1(+onst-at(1

to -(1*c( C"D ()(nts in pati(nts>it2 1ia0(t(s ACE in2i0ito-s,

ARBs, /0loc8(-s, 1i*-(tics, an1 calci*+

c2ann(l 0loc8(-s. A

All pati(nts >it2 1ia0(t(s an1 2p(-t(nsion

s2o*l1 0( t-(at(1 >it2 a -(gi+(n

t2at incl*1(s (it2(- an ACE

in2i0ito- o- an ARB. If on( class is not

tol(-at(1, t2( ot2(- s2o*l1 0( s*0stit*t(1.

If n((1(1 to ac2i()( 0loo1 p-(ss*-(

ta-g(ts, a t2ia6i1( 1i*-(tic s2o*l1

0( a11(1. E

If ACE in2i0ito-s, ARBs, o- 1i*-(tics a-(*s(1, +onito- -(nal f*nction an1 s(-*+

potassi*+ l()(ls. E

In pati(nts >it2 tp( 1ia0(t(s, >it2

2p(-t(nsion an1 an 1(g-(( of al0*+in*-ia,ACE in2i0ito-s 2a)( 0((n

s2o>n to 1(la t2( p-og-(ssion of n(p2-opat2.

A

In pati(nts >it2 tp( & 1ia0(t(s, 2p(-t(nsion,

an1 +ic-oal0*+in*-ia,

ACE in2i0ito-s an1 ARBs 2a)( 0((n

s2o>n to 1(la t2( p-og-(ssion to

+ac-oal0*+in*-ia. A In t2os( >it2 tp( & 1ia0(t(s, 2p(-t(nsion,

+ac-oal0*+in*-ia, an1 -(nal

ins*ffici(nc, ARBs 2a)( 0((n

s2o>n to 1(la t2( p-og-(ssion of n(p2-opat2.

A

In p-(gnant pati(nts >it2 1ia0(t(s an1c2-onic 2p(-t(nsion, 0loo1 p-(ss*-(

ta-g(t goals of @&:$95@!: ++3g

a-( s*gg(st(1 in t2( int(-(st of longt(-+

+at(-nal 2(alt2 an1 +ini+i6ingi+pai-(1 f(tal g-o>t2. ACE in2i0ito-s

an1 ARBs a-( cont-ain1icat(1 1*-ingp-(gnanc. E

In (l1(-l 2p(-t(nsi)( pati(nts, 0loo1

p-(ss*-( s2o*l1 0( lo>(-(1 g-a1*all

to a)oi1 co+plications. E

#ati(nts not ac2i()ing ta-g(t 0loo1

p-(ss*-( 1(spit( +*ltipl( 1-*g t2(-ap

s2o*l1 0( -(f(--(1 to a p2sician (=p(-i(nc(1

in t2( ca-( of pati(nts >it2 2p(-t(nsion.

E

O-t2ostatic +(as*-(+(nt of 0loo1

p-(ss*-( s2o*l1 0( p(-fo-+(1 in p(opl(

>it2 1ia0(t(s an1 2p(-t(nsion

>2(n clinicall in1icat(1. E

Position Statement

DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S!

3p(-t(nsion 0loo1 p-(ss*-( 4$:

++3g is a co++on co+o-0i1it of 1ia0(t(s,

aff(cting t2( +aJo-it of p(opl(

>it2 1ia0(t(s, 1(p(n1ing on tp( of 1ia0(t(s,

ag(, o0(sit, an1 (t2nicit. 3p(-t(nsion

is also a +aJo- -is8 facto- fo- C"D

an1 +ic-o)asc*la- co+plications s*c2 as

-(tinopat2 an1 n(p2-opat2. In tp(

1ia0(t(s, 2p(-t(nsion is oft(n t2( -(s*lt

of *n1(-ling n(p2-opat2. In tp( & 1ia0(t(s,

2p(-t(nsion +a 0( p-(s(nt aspa-t of t2( +(ta0olic sn1-o+( i.(., o0(sit,

2p(-glc(+ia an1 1slipi1(+ia

t2at is acco+pani(1 0 2ig2 -at(s of C"D.

Ran1o+i6(1 clinical t-ials 2a)( 1(+onst-at(1t2( 0(n(fit -(1*ction of C3D

()(nts, st-o8(, an1 n(p2-opat2 of lo>(-ing

0loo1 p-(ss*-( to4 ++3g sstolic

an1 ' ++3g 1iastolic in

in1i)i1*als >it2 1ia0(t(s 5@'.

Epi1(+iologic

anals(s s2o> t2at 0loo1

p-(ss*-(s 5$!5 ++3g a-( associat(1>it2 inc-(as(1 ca-1io)asc*la- ()(nt -at(s

an1 +o-talit in in1i)i1*als >it2 1ia0(t(s

5,:,. T2(-(fo-(, a ta-g(t 0loo1

p-(ss*-( goal of 7$' ++3g is -(asona0l(

if it can 0( saf(l ac2i()(1.

Alt2o*g2 t2(-( a-( no >(ll/cont-oll(1st*1i(s of 1i(t an1 (=(-cis( in t2( t-(at+(nt

of 2p(-t(nsion in in1i)i1*als >it2

1ia0(t(s, -(1*cing so1i*+ inta8( an1

0o1 >(ig2t >2(n in1icat(1, inc-(asingcons*+ption of f-*its, )(g(ta0l(s, an1

lo>/fat 1ai- p-o1*cts, a)oi1ing (=c(ssi)(alco2ol cons*+ption, an1 inc-(asing acti)it

l()(ls 2a)( 0((n s2o>n to 0( (ff(cti)(

in -(1*cing 0loo1 p-(ss*-( in

non1ia0(tic in1i)i1*als . T2(s(

nonp2a-+acological st-at(gi(s +a also

positi)(l aff(ct glc(+ia an1 lipi1 cont-ol.

T2(i- (ff(cts on ca-1io)asc*la-

()(nts 2a)( not 0((n >(ll +(as*-(1.


25/69

Lo>(-ing of 0loo1 p-(ss*-( >it2 -(gi+(ns

0as(1 on anti2p(-t(nsi)( 1-*gs,

incl*1ing ACE in2i0ito-s, angiot(nsin -(c(pto-

0loc8(-s ARBs, /0loc8(-s, 1i*-(tics,

an1 calci*+ c2ann(l 0loc8(-s,2as 0((n s2o>n to 0( (ff(cti)( in lo>(-ing

ca-1io)asc*la- ()(nts. S()(-al st*1i(ss*gg(st t2at ACE in2i0ito-s +a 0( s*p(-io-

to 1i21-op-i1in( calci*+ c2ann(l

0loc8(-s DCCBs in -(1*cing ca-1io)asc*la-

()(nts &,7. A11itionall, in

p(opl( >it2 1ia0(tic n(p2-opat2 in1icat(

t2at ARBs +a 0( s*p(-io- to DCCBs

fo- -(1*cing 2(a-t fail*-( 0*t not o)(-all

ca-1io)asc*la- ()(nts 4. Con)(-s(l,

in t2( -(c(ntl co+pl(t(1 Int(-national

"(-apa+il St*1 IN"EST of &&,

p(opl( >it2 CAD an1 2p(-t(nsion, t2(

non/DCCB )(-apa+il 1(+onst-at(1 asi+ila- -(1*ction in ca-1io)asc*la- +o-talit

to a /0loc8(-. Mo-(o)(-, t2is -(lations2ip

2(l1 t-*( in t2( 1ia0(tic

s*0g-o*p 5.ACE in2i0ito-s 2a)( 0((n s2o>n to

i+p-o)( ca-1io)asc*la- o*tco+(s in

2ig2@ ca-1io)asc*la- -is8 pati(nts >it2 o-

>it2o*t 2p(-t(nsion 9,!. In pati(nts

>it2 cong(sti)( 2(a-t fail*-( C3F,

t2( a11ition of ARBs to (it2(- ACE in2i0ito-s

o- ot2(- t2(-api(s -(1*c(s t2( -is8 of

ca-1io)asc*la- 1(at2 o- 2ospitali6ationfo- 2(a-t fail*-( ' @&. In on( st*1,

an ARB >as s*p(-io- to a /0loc8(- as a

t2(-ap to i+p-o)( ca-1io)asc*la- o*tco+(s

in a s*0s(t of 1ia0(tic pati(nts >it2

2p(-t(nsion an1 l(ft )(nt-ic*la- 2p(-t-op2

&. T2( co+p(lling (ff(ct ofACE in2i0ito-s o- ARBs in pati(nts >it2

al0*+in*-ia o- -(nal ins*ffici(nc p-o)i1(

a11itional -ational( fo- *s( of t2(s(

ag(nts s(( s(ction "I, B 0(lo>.T2( Anti2p(-t(nsi)( an1 Lipi1/

Lo>(-ing T-(at+(nt to #-()(nt 3(a-t Attac8T-ial ALL3AT, a la-g( -an1o+i6(1

t-ial of 1iff(-(nt initial 0loo1 p-(ss*-(

p2a-+acological t2(-api(s, fo*n1 no

la-g( 1iff(-(nc(s 0(t>((n initial t2(-ap

>it2 a c2lo-t2ali1on(, a+lo1ipin( an1 lisinop-il.

Di*-(tics app(a-(1 slig2tl +o-(

(ff(cti)( t2an ot2(- ag(nts, pa-tic*la-l

fo- -(1*cing

standar pengobatan dm

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