Natio n a l 

Diabe t e s 

Ed u c a tio n 

P r o g r a m 

Guiding Principles 

for Diabetes Care:

For Health Care 

Professionals
The goal of the National Diabetes Education Program (NDEP) is to reduce the morbidity and mortality caused by diabetes 

and its complications through educational efforts that increase awareness of the seriousness of the disease and the value of 

its management and prevention. Guiding Principles for Diabetes Care: For Health Care Professionals is a key resource to 

help all health care professionals assure that they are providing current, quality diabetes care. 

NDEP EXECUTIVE COMMITTEE

Francine Kaufman, M.D., Chair

Ann Albright, Ph.D., R.D.

Jeffrey Caballero, M.P.H.

Judith E. Fradkin, M.D.

Martha M. Funnell, M.S., R.N., C.D.E., Chair Elect 

Lawrence Blonde, M.D., F.A.C.P., F.A.C.E., Immediate Past Chair 

NDEP STEERING COMMITTEE MEMBERS

American Academy of Family Physicians

American Academy of Nurse Practitioners

American Academy of Pediatrics

American Academy of Physician Assistants

American Association of Clinical Endocrinologists

American Association of Diabetes Educators

American College of Physicians

American Diabetes Association

American Dietetic Association

American Medical Association

American Pharmacists Association

Association of American Indian Physicians

Association of Asian Pacific Community Health Organizations

Black Women’s Health Imperative

Diabetes Research and Training Centers

Juvenile Diabetes Research Foundation International

Khmer Health Advocates, Inc.

Lions Clubs International

National Alliance for Hispanic Health

National Association of School Nurses

National Hispanic Medical Association

National Latina Health Network

National Medical Association 

Papa Ola Lokahi

The Endocrine Society

FEDERAL LIAISONS TO THE

NDEP STEERING COMMITTEE

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention/Division of 

Diabetes Translation

Centers for Medicare and Medicaid Services

Indian Health Service

Council of State Diabetes Prevention and Control Programs

Bureau of Primary Health Care, Health Resources and Services 

Administration

National Institutes of Health/National Institute of Diabetes and 

Digestive and Kidney Diseases

National Kidney Disease Education Program

U.S. Veterans Administration Health Care System

NDEP STAFF

Joanne Gallivan, M.S., R.D., Director, NDEP, NIH

Rachel Weinstein, M.Ed., Deputy Director, NDEP, NIH

Susan McCarthy, M.P.H., C.H.E.S., Acting Director, NDEP, CDC

Betsy Rodríguez, M.S.N., C.D.E., Acting Deputy Director, NDEP, CDC

Elizabeth Warren-Boulton, R.N., M.S.N., Liaison, Hager Sharp, Inc.

Technical reviewers for the content of this resource

W. Lee Ball, Jr., O.D., FA.A.O.

Barbara Bartman, M.D.

Charles M. Clark Jr., M.D., NDEP Chair Emeritus

Judith Dempster, D.N.Sc., F.N.P., F.A.A.N.P.

Javier LaFontaine, D.P.M., M.Sc.

Margaret Gadon, M.D., M.P.H.

James R. Gavin III, M.D., Ph.D.

Amparo González, R.N., B.S.N., C.D.E.

J. Michael González-Campoy, M.D., Ph.D., 

F.A.C.E.

Mary Jo Goolsby, Ed.D., M.S.N., N.P-C, 

F.A.A.N.P.

JoAnn Gurenlian, R.D.H., Ph.D.

Sabrina Harper, M.S.

Joe Humphry, M.D.

Jane Kelly, M.D.

Sue Kirkman, M.D.

David Marrero, Ph.D.

Bob McNellis, M.P.H., P.A-C. 

Andrew Narva, M.D.

Sandra Parker, R.D., C.D.E.

Christy Parkin, M.S.N., R.N., C.D.E.

Kevin Peterson, M.D.

Susan A. Primo, O.D., M.P.H., F.A.A.O.

Tanya Pagán Raggio Ashley, M.D., M.P.H., 

F.A.A.P.

Michael Parchman, M.D., M.P.H., 

F.A.A.F.P. 

Leonard Pogach, M.D., M.B.A.

Donna Rice, M.B.A., B.S.N., R.N., C.D.E.

Julio Rosenstock, M.D.

Peter Savage, M.D.

Pamella Thomas, M.D., M.P.H., 

F.A.C.O.E.M., F.A.C.P.M.

Katherine R. Tuttle, M.D., F.A.S.N., 

F.A.C.P.

Sandeep Vijan, M.D., M.S.

Charlton Wilson, M.D.

Wilma Wooten, M.D., M.P.H.

The U.S. Department of Health and Human Services’ National Diabetes Education Program is 

jointly sponsored by the National Institutes of Heath and the Centers for Disease Control and Prevention 

with the support of more than 200 partner organizations.

www.YourDiabetesInfo.org 1-888-693-NDEP (6337) TTY: 1-866-569-1162

NIH Publication No. 09-4343 NDEP-16 Revised April 2009
1 

Table of Contents

Page 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Principle 1: Identify People with Undiagnosed Diabetes . . . . . . . . . . . . . . . . . . . . . 3

Principle 2: Manage Pre-Diabetes to Prevent or Delay the Onset of 

Type 2 Diabetes and Its Complications . . . . . . . . . . . . . . . . . . . . . . . . . 5

Principle 3: Provide Ongoing Self-Management Education and Support for 

People with Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Principle 4: Provide Comprehensive Patient-Centered Care to Prevent 

or Delay the Onset of Diabetes Complications and to Treat 

Diabetes and Existing Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Principle 5: Consider the Needs of Special Populations — Children, 

Women of Childbearing Age, Older Adults, and High-Risk 

Racial and Ethnic Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Principle 6: Provide Regular Assessments to Monitor Treatment 

Effectiveness and to Detect Diabetes Complications Early . . . . . . . 19

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2 

Introduction

These Guiding Principles for Diabetes Care: For Health Care Professionals provide an overview of the key elements 

of early and intensive clinical diabetes care and prevention. They form the basis of the National Diabetes Education 

Program’s (NDEP’s) public and professional awareness programs. The principles are based on the best level of 

evidence available, and key sources are noted. The NDEP adopts guidelines developed by the American Diabetes 

Association (ADA), and many have been incorporated into these guiding principles. Numerous other guidelines are 

available and some are noted in this document. It is essential that in practice, health care professionals focus on the 

similarities rather than the differences in diabetes-related guidelines. This document also provides links to supporting 

resources and further information. 

As the proportion of both minority populations and people aged 60 and older increases in the United States, and the 

obesity epidemic continues, people with diabetes are becoming a larger part of the practices of family physicians and 

other primary care clinicians. Health care professionals involved in new or expanding diabetes care practices can use 

these guiding principles to ensure that they provide essential components of comprehensive diabetes care. In addition, 

health care payers, managed care organizations, and large employers can use this information to establish diabetes care 

principles and to assure quality diabetes care and treatment options in health plans. 

NDEP encourages people with or at risk for diabetes and their families to participate actively with their health care 

team to plan and implement their care. While these principles serve as a guide for diabetes prevention and management, each person and his or her health care team should determine a specific prevention or management plan. 

Team care is essential for effective diabetes prevention and management. Team structure is best determined by the 

practice setting. Teams should be led by the most appropriate health care professional, and may include primary care 

physicians, diabetes educators, endocrinologists, dietitians, nurses, nurse practitioners, pharmacists, physician assistants, psychologists, dental professionals, exercise professionals, social workers, specialists for care of the eye, foot, 

heart, and kidney, and others as necessary. Many of these team members also may be certified diabetes educators. 

Trained lay educators such as “promotores” and community health workers can be effective team members. 

Other elements of importance to the delivery of diabetes care, in addition to team care, such as creating a patient 

registry, assessing practice needs, implementing processes of care, connecting to community resources, and evaluating 

outcomes are presented in detail on www.BetterDiabetesCare.nih.gov. This website provides tools and resources to 

help health care professionals implement systems changes. 

Early identification and management of pre-diabetes can delay or prevent the onset of type 2 diabetes. In people with 

type 1 and type 2 diabetes, ongoing comprehensive diabetes care, including the ABCs of diabetes (A1C for glucose, 

Blood pressure, and Cholesterol), can prevent or control diabetes-related microvascular and macrovascular complications. With proper medical management, education, self-care, and attention to behavior, social, and environmental 

factors, people with diabetes and pre-diabetes can live long, active, and productive lives. 
3 

Principle 1: 

Identify People with Undiagnosed Diabetes 

and Pre-diabetes

To improve health outcomes it is essential to identify people at high-risk for diabetes, as well as those 

who are undiagnosed, and treat them appropriately. 

Pre-diabetes occurs when a person’s blood glucose level 

is higher than normal but not high enough for a diagnosis of diabetes (Table 1). People with pre-diabetes have 

impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Some people have both IFG and IGT. It is 

important to assess patients for pre-diabetes or diabetes so 

they can be treated effectively and monitored for disease 

progression. Identify people at high-risk based upon 

known risk factors (Table 2). 

Consider testing plasma glucose if the person is: 

•	 Age 45 or older 

•	 An overweight adult with another risk factor (shown in 

Table 2). 

Consider repeat testing at least every three years.[1] 

Test plasma glucose in patients who have had hyperglycemia during acute illness or hospitalization, in people 

with cystic fibrosis, and in those on medications that predispose them to diabetes including anti-retroviral therapy 

for HIV, immunosupressants for transplantation, and 

atypical anti-psychotics. Inform these patients of their risk 

for diabetes and, if appropriate, encourage their actions to 

reduce risk as discussed in Principle 2.

Although the 2-hour 75g glucose challenge is more sensitive than a FPG value for diagnosing pre-diabetes or 

diabetes, use of the test is not always practical. If only a 

FPG is used, however, some diagnoses will be missed, 

particularly in elderly people. Clinical judgment should 

determine which test to use. 

The diagnosis of pre-diabetes and diabetes should be 

clear, based on accepted guidelines for FPG or IGT 

values. Avoid using terms with patients and their 

families, such as “a touch of diabetes” or “sugar is a 

little high” or “borderline diabetes” which suggest that 

diabetes is not serious. People should know whether they 

have pre-diabetes, type 1 or type 2 diabetes, or if they 

have or had gestational diabetes. They also need to understand what the diagnosis means and the steps to take to 

lower their risk for progression to diabetes, or to manage 

their disease. 

In 2007, at least 23.6 million Americans 

(7.8 percent of the population) had diabetes, 

of which 5.7 million had undiagnosed type 2 

diabetes. At least 57 million U.S. adults have 

pre-diabetes, placing them at increased risk for 

cardiovascular disease and type 2 diabetes. [2]

Table 1. Definitions of Pre-diabetes and Diabetes [1]

Pre-diabetes

IFG Fasting plasma glucose (FPG) 100–125 mg/dl 

after an overnight fast 

IGT 2-hr post 75g glucose challenge 140–199 mg/dl 

Diabetes

Random plasma glucose >200 mg/dl with 

symptoms (polyuria, polydypsia, and 

unexplained weight loss) and/or

FPG>126 mg/dl* and/or

2-hr plasma glucose>200 mg/dl* post 75g 

glucose challenge 

*

Repeat to confirm on a subsequent day unless 

symptoms are present.
4 

Table 3. Case Finding Recommendations for 

Women with History of Gestational 

Diabetes [6]

Time Test

Post-delivery (1–3 days) Fasting or random plasma

glucose (PG)

6 to 12 weeks postpartum 2-hr PG post 75g glucose 

challenge

1 year postpartum 2-hr PG post 75g glucose 

challenge

Annually Fasting PG

Every three years and before 

another pregnancy

2-hr PG post 75g glucose 

challenge

For NDEP patient resources for 

diabetes prevention see page 22.

Note 1. The American Association of Clinical Endocrinologists 

(AACE) promotes risk factors that differ from the above as follows: 

hypertension >135/85; HDL cholesterol level < 40; history of atherosclerotic vascular disease; women with PCOS – hyperadrogenism; and 

psychiatric illness. [4] 

Note 2. The U.S. Preventive Services Task Force (USPSTF) concludes 

that the evidence is insufficient to recommend for or against routinely 

screening asymptomatic adults for type 2 diabetes, impaired glucose 

tolerance, or impaired fasting glucose. [5] The USPSTF recommends 

screening for type 2 diabetes only in adults with dyslipidemia or 

sustained blood pressure (treated or untreated) over 135/80, in whom 

knowledge of diabetes status would lead to different blood pressure 

goals, or those with intermediate scores on cardiovascular disease 

(CVD) risk engines in whom knowledge of diabetes status would trigger statin use. www.ahrq.gov/clinic/3rduspstf/diabscr/diabetrr.htm

Women with a history of gestational diabetes are at 

increased lifelong risk for diabetes. They should be tested 

for diabetes or pre-diabetes periodically as noted in 

Table 3:

Table 2. Risk Factors for Type 2 Diabetes [1]

Overweight adult: Body Mass Index ≥25 kg/m2 (≥23 if Asian

American or ≥26 if Pacific Islander) with one or more of the

following:

•	 Family history: have a first-degree relative with diabetes 

•	 Race/Ethnicity: African American, Hispanic/Latino, 

American Indian and Alaska Native, or Asian American 

and Pacific Islander

•	 History of gestational diabetes or gave birth to a baby 

weighing > 9 lbs 

•	 Hypertension: blood pressure >140/90 

•	 Abnormal lipid levels: HDL cholesterol level <35mg/dl; 

triglyceride level >250 mg/dl 

•	 IGT or IFG: on previous testing 

•	 Signs of insulin resistance: such as acanthosis nigricans or 

polycystic ovarian syndrome (PCOS)

•	 History of vascular disease: diagnosed by physical exam 

and testing

•	 Inactive lifestyle: being physically active less than three 

times a week 

In the absence of the above risk factors, people age 45 and 

older are considered at risk and should be tested.
5 

Principle 2: 

Manage Pre-Diabetes to Prevent or Delay 

the Onset of Type 2 Diabetes and 

Its Complications

People with pre-diabetes are at risk of developing type 2 diabetes and cardiovascular disease. As found 

in the Diabetes Prevention Program (DPP)[7], lifestyle interventions in people at high-risk can reduce their 

risk of developing type 2 diabetes by more than half. This powerful reduction in risk of type 2 diabetes 

affects all subgroups including men and women, high-risk racial groups, women with a history of 

gestational diabetes, and is even greater in people age 60 and older. 

Progression to type 2 diabetes among people with pre-diabetes is not inevitable. 

Disease progression

Progression to type 2 diabetes among people with prediabetes is not inevitable. About 5 percent of the lifestyle 

intervention group developed diabetes each year during 

the study period compared with 11 percent per year in 

those who did not get the intervention. People at risk for 

diabetes need to understand what pre-diabetes means and 

the steps to take to lower their risk for diabetes. 

Children whose BMI is >85th percentile for their age 

are at increased risk for developing type 2 diabetes. They 

should be counseled to increase physical activity and 

reduce their rate of weight gain while allowing for normal 

growth and development.

High-risk older adults can significantly reduce their risk 

of developing type 2 diabetes through lifestyle changes. 

The DPP found lifestyle interventions in people at highrisk age 60 and older reduced their risk of developing 

type 2 diabetes by 71 percent. Medicare Part B now 

offers older adults preventive care benefits including a 

“Welcome to Medicare” physical exam, and diabetes and 

cardiovascular screening tests for people at risk. www.cms.

hhs.gov/MLNProducts/downloads/expanded_benefits_06-08-05.pdf

Women with a history of gestational diabetes need to 

be counseled about their increased lifelong risk for diabetes and ways to lower their risk. Children of women 

with gestational diabetes also are at increased lifelong 

risk for diabetes. [8] The mother’s history of gestational 

diabetes should be noted in the child’s medical record. 

Breastfeeding may help prevent obesity in these children 

and may lower their risk for type 2 diabetes. Since families share lifestyle habits, following a healthy lifestyle can 

benefit the mother and her children by lowering their risk 

for type 2 diabetes. 

Lifestyle modification 

Based on the DPP findings, NDEP promotes actions to 

prevent or delay the onset of type 2 diabetes in people 

at risk and provides a toolkit for health care professionals. Lifestyle modification with a low-fat, reduced-calorie 

meal plan and increased physical activity should be 

discussed with all people who have pre-diabetes (Table 

4). Refer to community resources whenever possible. 

(See Resource section for Small Steps. Big Rewards. Your 

GAME PLAN to Prevent Type 2 Diabetes: Health Care 

Provider Toolkit and The Road to Health Toolkit — a 

multi-component primary prevention resource.) 

Medication therapy

To prevent or delay the onset of type 2 diabetes, 

therapy may include the insulin-sensitizing medication 

metformin for some people with pre-diabetes (Table 5).

In the DPP, individuals with IGT who took metformin 

reduced their risk of developing diabetes by almost onethird. Metformin was more effective in younger, heavier 

people and less effective in people over the age of 60. [9] 

Metformin is not FDA approved for treatment of 

pre-diabetes.

Antihypertension and lipid-modifying medications and 

aspirin should be used to treat and modify cardiovascular 

risk as appropriate. 
6 

Table 4. Lifestyle Modification for Diabetes 

Prevention or Delay of Onset

Collaborating with patients to set short-term, specific, realistic 

goals can help support lifestyle change efforts. 

Nutrition therapy:

•	 An integral part of a healthy, sustained weight loss 

program is the subtraction of calories each day from the 

diet. For most people, weight loss diets should supply 

at least 1,000 to 1,200 kcal/day for women and 1,200 to 

1,600 kcal/day for men.

•	 Total fat should be 25 to 35 percent of total calories and 

saturated fat less than 7 percent. 

•	 Portion control is essential for weight loss.

Physical activity:

•	 Patients should get at least 30 minutes of moderateintensity physical activity five days a week. Daily activity time can be broken into segments. Brisk walking is 

an excellent form of moderate-intensity physical activity. 

www.health.gov/paguidelines/default.aspx

•	 NDEP provides tools to help people track their daily food, 

calorie, and fat intake, as well as physical activity. 

Behavior therapy: [3]

•	 Knowledge is essential but rarely adequate to sustain 

behavior change over the long-term.

•	 Effective behavioral strategies that patients can use in their 

efforts to modify their lifestyles include: self-monitoring, 

stress management, stimulus control, problem-solving, 

self-directed goal-setting, cognitive restructuring, and 

social support.

•	 Behavioral therapies may help adoption of diet and activity 

changes.

Weight loss: 

•	 Realistic yet clinically meaningful weight loss goals call 

for a 5 to 7 percent reduction in initial weight (10 to14 

pounds (4.5 to 6.3 kg) for a 200-pound (90.6 kg) person).

Follow-up and referral: 

•	 A focus on improved glucose and cholesterol levels, blood 

pressure, and self-esteem can reinforce the importance of 

lifestyle changes that lead to modest weight loss. 

•	 Follow-up and monitoring of a patient’s progress is 

essential.

•	 Referral to registered dietitians and weight control or wellness clinics can help patients maintain lifestyle changes.

Obesity medications and surgery

Weight loss medications approved by the FDA may be 

used as part of a comprehensive weight loss program that 

includes meal planning and moderate intensity physical 

activity and behavior therapy for people with a BMI >30 

or >27 with concomitant obesity-related risk factors or 

diseases. Continual assessment of obesity drug therapy for 

efficacy and safety is necessary. [3, 10] 

Weight loss surgery is an option in carefully selected 

obese adults and older adolescents who have completed 

growth (BMI >35 with comorbid conditions such as 

diabetes; BMI>50 or >40 with comorbid condition in 

adolescents) when less invasive methods of weight loss 

have been unsuccessful and the patient is at high risk for 

obesity-associated morbidity or mortality. [11, 12]

Table 5. Addition of Metformin to Lifestyle 

Changes [9]

The use of metformin may be considered in addition to lifestyle changes to prevent or delay the onset of diabetes in individuals with IFG and IGT and one or more of the 

following: 

•	 Age <60 years 

•	 BMI >35 kg/m2

•	 Family history of diabetes in first-degree relatives

•	 Elevated triglycerides

•	 Reduced HDL cholesterol

•	 Hypertension

•	 A1C >6.0 percent

Metformin is not FDA approved for treatment of pre-diabetes.

For NDEP patient resources for 

diabetes prevention see page 22.
7 

Self-management training

Diabetes educators and other health care team members 

provide DSME to address the educational, clinical, 

behavioral, and emotional needs of the individual patient 

in a supportive environment. Using a patient-centered 

approach engages the patient in active collaboration with 

the diabetes team and enables the patient to create a workable self-management plan based on age, school, or work 

schedule, as well as daily activities, culture, religious practices, competing priorities, family demands, eating habits, 

physical abilities, and health problems. These experts are 

able to help the patient achieve the highest possible level 

of self-care and quality of life.

Patients with severe visual impairment can learn selfmanagement skills such as self-glucose monitoring, 

foot exam, and insulin use with the assistance of talking 

glucose meters and insulin dosing devices and by learning 

non-visual techniques. Organizations such as the National 

Federation of the Blind (www.nfb.org) offer resources and 

education support.

Education and ongoing support process

The overall objectives of DSME are to support informed 

decision-making, self-care behaviors, problem-solving, 

healthy coping and active collaboration with the health 

care team and to improve clinical outcomes, health status, 

and quality of life. While there is no one “best” education approach, programs that incorporate behavioral and 

psychosocial strategies demonstrate improved outcomes. 

Studies also show that culturally and age appropriate 

programs improve outcomes and that group education 

is effective. Standards for DSME have been developed 

through collaborative efforts of the key diabetes organizations. [13] In addition, the American Association of 

Diabetes Educators (AADE) identified seven self-care 

behaviors as a method for categorizing patient behaviors. 

(Table 6)

DSME is effective for improving metabolic and psychosocial outcomes, at least in the short term. As a result of 

DSME, people learn about diabetes and its management, 

define personal goals and strategies to reach those goals, 

make informed choices about therapies, develop behavioral and coping skills to support those choices, and evaluate the effectiveness of their efforts. Ongoing diabetes 

self-management support is critical for patients to sustain 

the gains made during DSME. [14]

Communication strategies

Effective communication can improve self-efficacy, 

support patients’ behavior change efforts, and facilitate 

healthy coping. Effective strategies such as motivational 

interviewing are designed to assist patients to identify 

their own concerns, supports, and challenges and strategies to overcome barriers. Conversation maps are selfdiscovery learning tools that can help engage patients 

around self-management issues. For resources to help 

health care professionals enhance their communication 

skills, visit www.betterdiabetescare.nih.gov/WHATpatient 

centerededucation.htm; www.diabetesincontrol.com/

issues/ issue317/about_healthyi.pdf.

Financial Resources

Medicare covers diabetes self-management education 

from a recognized program, medical nutrition therapy 

from a registered dietitian, and diabetes equipment 

and supplies (i.e., blood glucose meters, test strips, and 

lancets). Other diabetes-related items covered include 

A1C and cholesterol tests, a dilated eye exam, glaucoma 

screening, flu and pneumococcal pneumonia shots, and 

a foot exam by a podiatrist if nerve damage is present. 

Medicare Part D offers prescription drug plans for enrollees. Most other insurance providers offer similar coverage 

for people with diabetes. 

Principle 3: 

Provide Ongoing Self-Management 

Education for People with Diabetes 

Effective patient self-management is essential for people to live well with diabetes. It enables them to 

make informed decisions and to assume responsibility for the day to day management of their disease. 

Diabetes self-management education (DSME), also called diabetes self-management training, gives 

people with diabetes the knowledge, skills, and tools they need to effectively manage their diabetes. 

Ongoing support for coping with the daily demands of living successfully with diabetes is critical. 
8 

Recognition of quality care

To promote quality education for people with diabetes, the 

ADA recognizes programs that meet National Standards 

for Diabetes Self-Management Education Programs. The 

National Standards for DSME define quality diabetes selfmanagement education and assist diabetes educators in a 

variety of settings to provide effective education. ADA 

and the National Committee for Quality Assurance also 

recognize physicians that voluntarily meet performance 

measures of adult or pediatric care. www.diabetes.org/

for-health-professionals-and-scientists/recognition.jsp

For NDEP resources for people 

with diabetes see page 22. 

Table 6. AADE7 Self-Care BehaviorsTM: 

Summary of Diabetes Educator 

Assistance with Patient Self-Care 

Behaviors 

Healthy eating 

Diabetes educators help people learn about the effect of food 

on blood glucose and sources of carbohydrates, protein, and 

fat, make healthy food choices, adjust portion sizes, read 

labels, count carbohydrates, and plan and prepare meals. 

Being active

Diabetes educators and their patients collaborate to address 

barriers, such as physical, environmental, psychological, and 

time limitations. They develop an appropriate activity plan 

that balances food and medication with the activity level. 

Monitoring 

Diabetes educators can instruct patients about self-monitoring 

blood glucose equipment choice and selection, timing and 

frequency of testing, target values, and interpretation and use 

of results. Patients are taught to regularly check their blood 

pressure, urine ketones, and weight, as appropriate.

Taking medication 

The goal is for the patient to learn about each medication, 

including its action, side effects, efficacy, toxicity, prescribed 

dosage, appropriate timing and frequency of administration, 

effect of missed and delayed doses, and instructions for injection, storage, travel, and safety. 

Problem solving 

Collaboratively, diabetes educators and patients address 

barriers, such as physical, emotional, cognitive, and financial 

obstacles, and develop coping strategies. 

Reducing risks 

Diabetes educators assist patients in gaining knowledge 

about standards of care, therapeutic goals, and preventive 

care services to decrease risks. Skills taught include smoking 

cessation, foot inspections, blood pressure monitoring, selfmonitoring of blood glucose, aspirin use, and maintenance of 

personal care records. 

Healthy coping 

Diabetes educators can identify the patient’s motivation to 

change behavior, then help the patient set achievable 

behavioral goals, address barriers, and develop coping skills. 

The educator can assess patients for depression and refer for 

therapy. 

www.diabeteseducator.org/ProfessionalResources/ AADE7
9 

A major limitation to available data is thatthe optimum 

levels of control for particularpatients are not identified, 

as there are individual differences in the risks ofhypoglycemia, weight gain, and other adverse effects. Further,

with multifactorial interventions, it is unclear how different components (e.g., educational interventions, glycemic 

targets, food selection, lifestyle changes, and medications) 

contribute to the reduction of complications. The level of 

evidence for a given guideline should be considered when 

individualizing targets. 

Intensification of treatment over time is essential for 

people with type 2 diabetes so that they continue to meet 

therapeutic goals. It should be made clear that progress 

toward treatment targets is important since the absolute 

benefits lessen the closer one gets to the goal. Clinicians 

may choose to use health risk calculators such as Diabetes 

PHD (www.diabetes.org/diabetesphd/default.jsp) or the 

UKPDS Risk Engine (www.dtu.ox.ac.uk/index.php? 

maindoc=/riskengine/) to review estimates of the magnitude of absolute risk reduction as part of a treatment 

plan, especially in the context of intensifying treatment at 

values marginally above treatment goals. Treatment goals 

for A1C, blood pressure, and LDL-cholesterol that are 

recommended by the ADA and promoted by the NDEP 

are listed in Table 7.

Evidence for benefits of good blood glucose 

control

The Diabetes Control and Complications Trial (DCCT) 

[15] found that individuals with type 1 diabetes who 

achieved tight glucose control reduced microvascular 

complications up to 75% during the trial. The Epidemiology of Diabetes Interventions and Complications [16] 

follow-up study of participants in the DCCT showed that 

participants also had lasting benefits years later. Benefits 

included major reductions in eye, nerve, kidney, and heart 

complications with less than half the number of cardiovascular disease (CVD) events than the conventionally 

treated group.

Similarly, the 10-year follow-up of the United Kingdom 

Prospective Diabetes Study (UKPDS) [17] in people 

with type 2 diabetes found that although differences in 

glycemic control between intensive (A1C goal 7%) and 

standard treatment were lost within a year of the end of the 

original trial, significant microvascular benefits persisted 

at 10 years, and significant macrovascular benefits, including reduced myocardial infarction, emerged in the insulin/

sulfonylurea group and persisted in the metformin group. 

Findings from three other recent clinical trials (ACCORD, 

ADVANCE, VADT*) indicate that caution is needed in 

setting A1C goals lower than 7% in people with longstanding type 2 diabetes who have CVD or multiple CVD 

risk factors.

Principle 4: 

Provide Comprehensive Patient-Centered 

Care to Prevent or Delay the Onset of 

Diabetes Complications and to Treat 

Diabetes and Existing Complications

Good management of blood glucose (A1C*) levels can reduce symptoms related to diabetes and reduce 

the risk of both acute and chronic complications. Additional interventions to control blood pressure 

and cholesterol levels, along with smoking cessation, can significantly lower risk for long-term diabetes 

complications. The health care team should work in partnership with the patient to determine an individualized diabetes management plan, discussing options, goals, and individualized targets linked to 

the plan. Factors such as life expectancy, risk of hypoglycemia and the presence of advanced diabetes 

complications, or other medical conditions need to be taken into account when deciding which target 

values are most appropriate for an individual. 

* NDEP and it partners have adopted the simple name “A1C” for the hemoglobin A1C test.
•	 In the ACCORD trial, over an average period of 3.5 

years, more intensive blood glucose control (“nearnormal”A1C goal < 6.0%) in older patients (mean age 

62 years) with a 10 year average duration of diabetes 

and known CVD or with multiple CVD risk factors 

was associated with an approximately 20% increase in 

overall and cardiovascular mortality compared to standard glucose control (A1C goal 7.0-7.9%).

o All three trials showed trends toward lower rates of 

 non-mortality CVD outcomes with more intensive 

 blood glucose control, but none were statistically 

 significant.

•	 All three trials showed that more intensive glucose 

control increased the risk of severe hypoglycemia. 

•	 Confirming earlier evidence, the ADVANCE trial 

showed that more intensive blood glucose control 

lowered the risk of new or worsening microvascular 

complications, particularly new onset microalbuminurea and new or worsening nephropathy. 

* ACCORD – Action to Control Cardiovascular Risk in Diabetes [18] 

ADVANCE – Action in Diabetes and Vascular disease: PreterAx 

and DiamicroN MR Controlled Evaluation [19] 

VADT – Veterans Affairs Diabetes Trial [20] 

Evidence for blood pressure control

Blood pressure reduction also substantially improves 

clinical outcomes. In the UKPDS, tight blood pressure 

control which targeted <150/85 (achieved 144/82 mmHg) 

compared to a target of 180/105 significantly reduced risk 

for diabetes-related deaths, stroke, heart failure, microvascular disease, retinopathy progression, and deterioration 

of vision in people with type 2 diabetes. [21] However, 

in the 10-year follow up of the UKPDS [22], differences 

in blood pressure control were lost within two years of 

the end of the original trial, and at 10 years there was 

no difference in outcomes attributable to blood pressure 

control. These finding indicate that benefits of blood 

pressure control do not extend beyond the period of 

intensified therapy, and ongoing treatment is essential. 

The effectiveness of reducing diastolic treatment 

goals in people with diabetes was demonstrated by the 

Hypertension Optimal Treatment study that found a 51 

percent reduction in major cardiovascular events at a 

diastolic goal of 80 mmHg compared with 90 mmHg. 

[23] These findings together with epidemiologic evidence 

led to the ADA recommended blood pressure level of 

130/80 for people with diabetes. The ongoing ACCORD 

trial will provide additional information on whether a 

systolic BP target <120 has better outcomes than a target 

<140 mmHg in patients with type 2 diabetes.

The Systolic Hypertension in Elderly Program study 

found that diuretics reduced cardiovascular death in 

people with diabetes by 31 percent. [24] Angiotensin 

converting enzyme (ACE) inhibitors have been demonstrated to provide substantial benefits, including reduced 

risk of heart attack, stroke, or cardiovascular death [25, 

26] and prevention of progression of nephropathy. [27] 

The recent ADVANCE study assessed the effects of 

the routine administration of an ACE inhibitor-diuretic 

combination in patients with diabetes and found a significant reduction in relative risk of a major macrovascular or 

microvascular event, death from cardiovascular disease, 

and death from any cause. [28] 

Evidence for lipid control

People with diabetes commonly have lipid patterns 

characterized by elevated triglyceride and reduced 

HDL-cholesterol levels. While their LDL-cholesterol 

values are generally not higher than those in non-diabetic 

individuals, there is often a greater proportion of smaller, 

denser and more atherogenic LDL particles. [29] Studies 

using the HMG-CoA reductase inhibitors (statins) have 

clearly shown that rigorous LDL-cholesterol reduction therapy can reduce the risk of CVD in people 

Guiding Principles Based on the Above Findings 

and DCCT/EDIC and UKPDS

•	 Customary levels of intensive glucose control (A1C goal 

<7%) in newly diagnosed people with either type 1 or 

type 2 diabetes not only has benefits during the period of 

intensive therapy but also has a “legacy effect” in which 

microvascular and macrovascular benefits are maintained 

or realized years later. 

> Starting optimal blood glucose management as early 

 as possible and maintaining it as long as possible with

 out inducing significant hypoglycemia in people with 

 either type 1 or type 2 diabetes is beneficial.

•	 While the usual A1C goal for most people with diabetes is 

<7%, treatment must be individualized. 

> Less intensive control may be appropriate in older 

 people; those with epilepsy; people with long-standing 

 diabetes and CVD or multiple risk factors; those with 

 advanced diabetes complications such as chronic 

 kidney disease or autonomic neuropathy; or others at 

 risk of severe hypoglycemia.

> More intensive control to near-normal A1C levels may 

 be appropriate for people with new-onset diabetes who 

 have a long life expectancy and do not have CVD or 

 multiple risk factors, or other co-morbidities, that 

 increase risk of hypoglycemia or other adverse effects 

 of treatment. 

10 
11 

with diabetes.[30-33] Current guidelines recommend 

LDL-cholesterol less than 100 mg/dl in patients with 

diabetes. Some experts recommend optional, more 

aggressive lowering (<70 mg/dl) in patients with clinical 

CVD or at high risk of CVD. [1] 

Multiple risk factor reduction

In the Steno-2 Study [34], a target-driven, long-term, 

intensified intervention aimed at multiple risk factors 

in patients with type 2 diabetes and microalbuminuria, 

the risk of cardiovascular and microvascular events was 

reduced by about 50 percent. This study clearly demonstrated the value of addressing A1C, BP, and LDLcholesterol, the ABCs of diabetes. Long-term follow-up 

of the participants found significant sustained reductions 

in cardiovascular deaths. [35]

Weight loss

One-year data from the Look AHEAD (Action for Health 

in Diabetes) study [36] show that intensive lifestyle intervention in people with diabetes for weight loss through 

changes in diet and physical activity reduced body weight, 

A1C, systolic and diastolic blood pressure, and triglycerides, and increased HDL cholesterol. Fewer diabetes and 

anti-hypertensive medications were needed in the intensive intervention group. This ongoing trial will determine 

the effects of weight loss on long-term complications of 

type 2 diabetes.

Blood glucose management

As noted, the risk for microvascular and macrovascular 

complications of both type 1 and type 2 diabetes can be 

reduced by maintaining A1C close to 7%. The absence 

of symptoms of high blood glucose is an unreliable guide 

for judging glucose control, since symptoms do not 

occur until blood glucose reaches high levels. Diabetes is 

often called a “silent disease” because it can cause serious complications without having serious symptoms. 

The initiation and adjustment of therapy needs to target 

metabolic control as close to goal as possible without 

compromising patient safety. Patients on insulin or oral 

agents that stimulate insulin secretion are likely to have 

an increasing risk of hypoglycemia with an A1C below 

7. Medical nutrition therapy and physical activity are 

essential from diagnosis onward for people with diabetes. For type 1 diabetes insulin is required at the onset 

of disease. For people with type 2 diabetes, the addition 

of metformin, combination therapy with other glucoselowering medications, basal insulin, and prandial insulin, 

may become necessary over time to maintain the target 

A1C. Algorithms can help guide therapy selection. [39] 

Note 1. Similar recommendations for A1C, blood pressure, or 

cholesterol are available from:

•	 AACE (www.aace.com/pub/pdf/guidelines/DMGuidelines 

2007.pdf) 

•	 JNC7 the Seventh Report of the Joint National Committee 

on Prevention, Detection, Evaluation, and Treatment of High 

Blood Pressure (www.nhlbi.nih.gov/guidelines/hypertension/)

•	 National Kidney Foundation (www.kidney.org/professionals/

KDOQI/guidelines.cfm) and the National Kidney Disease 

Education Program (www.nkdep.nih.gov/)

•	 National High Blood Pressure Education Program 

(NHBPEP) (www.nhlbi.nih.gov/about/nhbpep/)

•	 National Cholesterol Education Program (www.nhlbi.nih.gov/

about/ncep/)

•	 American College of Physicians: Glycemic control and type 

2 diabetes mellitus: the optimal hemoglobin A1c targets 

(www.annals.org/cgi/reprint/147/6/417.pdf); Lipid control 

in the management of type 2 diabetes mellitus (www.annals.

org/cgi/reprint/140/8/644.pdf); The evidence base for tight 

blood pressure control in the management of type 2 diabetes 

mellitus (www.annals.org/cgi/reprint/138/7/587.pdf) 

Note 2. A comprehensive assessment of North American and 

United Kingdom Glycemic Control Guidelines commissioned 

by the American College of Physicians is available. [38]

Table 7. ABC Treatment Goals for People with 

Diabetes [1] [37] 

A1C <7.0 percent for patients with diabetes, in general*

Plasma blood glucose:

 Preprandial capillary plasma glucose 70–130 mg/dl

 Peak postprandial capillary plasma glucose 

 <180 mg/dl (usually 1 to 2 hours after the start of a 

 meal)

 Be alert to the impact of hemoglobin variants on A1C 

values. For information see www2.niddk.nih.gov/variants

Blood Pressure <130/80 mmHg (if it can be achieved 

safely)

Cholesterol – Lipid Profile (mg/dl)

 LDL <100 (for those with CVD <70)

 HDL Men >40 Women >50

 Triglycerides <150

*Individualize target levels as appropriate. For example 

consider:

•	 A1C target as close to normal as possible without 

significant hypoglycemia in selected individuals such as

those with short duration of diabetes, little comorbidity 

and long life expectancy.

•	 Less strict A1C target for people with severe hypoglycemia, limited life expectancy, comorbid conditions, 

advanced micro- or macrovascular complications, or longstanding diabetes. 
12 

A1C values [40] and self-monitoring of blood glucose 

(SMBG) should be used to guide therapy to achieve 

glycemic targets. A1C is a standardized blood test that 

indicates the average blood glucose over the previous 8 

to 12 weeks. People with diabetes should know their own 

A1C values (which may be interpreted by a calculated 

estimated average glucose or eAG ) to determine whether 

they are reaching their targets. Labs may provide both 

A1C and the eAG equivalent. (See box below for conversion table and reference 40 for further information.) 

Regular SMBG may help with self-management, such 

as changing medications, particularly for individuals 

taking insulin. SMBG can also be used to assess symptoms of hypoglycemia and hyperglycemia. Individual 

circumstances will define how often self-monitoring is 

used, the specific testing method, and the way to record 

and report results.

Both measures of long term control (A1C along with 

eAG) and measures of SMBG are valuable for assessing 

the adequacy of glycemic control and adjusting medications in patients with diabetes. While the A1C level 

gives an overall estimate of control over several weeks, 

the SMBG values can assess the variability of short term 

glucose levels. The latter may be important to reduce 

post prandial hyperglycemic excursions or to confirm 

symptomatic or otherwise unrecognized hypoglycemia. 

During unstable periods, patients may need to increase the 

frequency of SMBG determinations.

For type 1 diabetes, basal and meal-related insulin doses 

may be prescribed several times a day via multiple injections or an insulin pump in an attempt to normalize 

glucose metabolism and simulate normal insulin physiology. Several types of glucose-lowering medications are 

available for the treatment of type 2 diabetes. These medications differ by their mechanism of actions that serve to: 

enhance endogenous insulin secretion, inhibit excessive 

hepatic glucose production, enhance insulin sensitivity in 

muscle and adipose tissue, delay gastrointestinal carbohydrate absorption, delay gastric emptying, inhibit glucagon 

secretion, and enhance satiety. These medications may be 

prescribed alone or in some combinations to meet treatment goals. Medications used to treat patients with diabetes are summarized on the NDEP website. (See Resource 

section for Working Together to Manage Diabetes: 

Diabetes Medications Supplement).

It has been shown that endogenous insulin levels decrease 

over time in people with type 2 diabetes, and most 

patients eventually require insulin replacement therapy if 

they are to attain and sustain glycemic targets. Informing 

these patients that beta cell function decreases over time, 

may help prepare them for the moment when the addition 

of insulin therapy may become necessary. It is critical that 

patients understand the importance of insulin therapy and 

the dangers of postponing its initiation when oral medications are no longer effective. The use of more predictable 

short and long-acting insulin analogs significantly reduces 

risk of hypoglycemia. Pen delivery devices also facilitate 

insulin administration and acceptance of insulin therapy. 

Clinicians are encouraged to rely upon systematic reviews 

of the comparative effectiveness of glucose-lowering 

medications and insulin from sources such as the Agency 

for Healthcare Quality and Research [41] and Cochrane 

reviews (www.cochrane.org/reviews: Long-acting insulin 

analogues versus NPH insulin (human isophane insulin) 

for type 2 diabetes mellitus. Cochrane Database Syst Rev. 

2007 Apr 18;(2):CD005613). 

Note that in the hospital setting, effective glycemic control 

is important in order to improve patient outcomes. [1] 

Results of the A1C-Derived Average Glucose study affirmed 

the existence of a linear relationship between A1C and average blood glucose levels. As a result, the ADA is promoting 

use of estimated average glucose or eAG. Patients will be 

able to receive A1C% and/or eAG values that relate to blood 

glucose values in mg/dl.

Formula 28.7 X A1C – 46.7 = eAG. 

Conversion Table

A1C eAG

% mg/dl mmol/l

6 126 7.0

6.5 140 7.8

7 154 8.6

7.5 169 9.4

8 183 10.1

8.5 197 10.9

9 212 11.8

9.5 226 12.6

10 240 13.4
13 

Lipid and blood pressure management

Dyslipidemia and hypertension commonly coexistwith 

type 2 diabetes and are clear risk factors for cardiovascular disease; and diabetes itself confers independent

risk. Extensive trial evidence shows the efficacy of lipidlowering therapy and targeted treatment of hypertension 

to prevent or slow cardiovascular disease onset inpeople 

with diabetes. 

Lipid and blood pressure levels should be treated more 

aggressively in patients with diabetes than in the general 

population [1] because of the increased risk of cardiovascular and kidney diseases. Clinical trials have demonstrated clear benefits of hypertension control on both 

macro- and microvascular complications of diabetes. In 

addition, significant benefits of lowering LDL-cholesterol 

have also been demonstrated in clinical trials conducted in 

patients with diabetes. Taken together, improved management of glucose, blood pressure and LDL-cholesterol, 

along with abstinence from smoking, can lead to major 

reductions in the risk of both small and large vessel 

complications associated with diabetes. [1]

Lipid management 

To reduce the risk of cardiovascular disease, blood lipids 

need regular measurement and effective management — 

especially high LDL cholesterol, high total cholesterol, 

and low HDL cholesterol. Statins are the initial medications of choice for most people with elevated LDL cholesterol. 

•	 Lifestyle modification to reduce saturatedfat, trans fat, 

and cholesterol intake; weight loss (if indicated); and 

increased physical activity should be recommended. 

•	 Statin therapyshould be added to lifestyle therapy, 

regardlessof baseline lipid levels, for diabetic patients 

with overtCVD and those withoutCVD who are over 

the age of 40 and have oneor moreother CVDrisk 

factors. 

•	 For lower-risk patients withoutovert CVD and under 

the age of 40, statintherapy should be considered in 

addition to lifestyle therapyif LDL cholesterolremains 

>100 mg/dl or in those patients with multipleCVD risk 

factors.

•	 In individuals without overt CVD, theprimary goal is 

an LDLcholesterol <100 mg/dl. 

•	 In individuals with overt CVD, a lower LDL cholesterol

goalof <70 mg/dl, using a high dose statin,is an option. 

Blood pressure management

Blood pressure management has been proven to reduce 

both microvascular and macrovascular diabetes complications. Control of hypertension is essential in order to 

reduce cardiovascular risk and kidney and eye disease risk. 

•	 Strategies to reduce sodiumintake and excess body 

weight, such as increasing consumption of fruits,

vegetables, and low-fat dairy products, avoiding excessive alcohol consumption, and increasing activity levels, 

may have antihypertensive effects similar to pharmacologic monotherapy. 

•	 In individuals with diabetes and mild hypertension

(systolic blood pressure 130–139 mmHg or diastolic 

bloodpressure 80–89 mmHg), an initial trial of nutrition and physical activity therapymay be reasonable.

•	 If the blood pressure is 140 mmHgsystolic and/or 90 

mmHg diastolic at the time of diagnosis,pharmacologic 

therapy should be initiated along with nutrition and 

physical activitytherapy. 

Medications used in the treatment of hypertension include 

thiazide diuretics, ACE inhibitors, angiotensin receptor 

blockers (ARBs), ACE inhibitor-diuretic combinations, 

beta blockers, and calcium channel blockers. Multidrug 

therapy usually is required to achieve and maintain a 

blood pressure goal of <130/80 mmHg that is recommended for most people with diabetes. At every visit to 

the health care team, blood pressure should be measured 

and treatment adjusted if necessary. 

Other components of comprehensive diabetes 

care include (in alphabetical order):

Anti-platelet therapy [1]

Using aspirin therapy (75–162 mg/day) is recommended 

as a preventionstrategy for cardiovascular events in those 

patients with diabetes who have a history of CVD or are 

at high CVD risk. 

Dental care

Poor glycemic control may exacerbate periodontal disease 

and tooth decay. Conversely, periodontal disease may 

cause deterioration of glycemic control. All patients with 

diabetes should be encouraged to brush and floss their 

teeth after every meal, and to have professional dental 

cleaning at least once a year.
14 

Depression management

The presence of diabetes may double the risk of 

depression. The risk increases as diabetes complications 

worsen. People who are depressed are less able to carry 

out self-management tasks. Screening for depression 

and treating it effectively can help improve diabetes 

management. The Patient Health Questionnaire (PHQ)-9 

is a brief 9 item depression self-report scale that is an 

effective tool used to screen and diagnose depression 

as well as to monitor response to therapy. http://

www.ihs.gov/MedicalPrograms/ Diabetes/resources/

bp06_DepressionCare.pdf. Treatment of depression 

with psychotherapy, medication, or a combination of 

these treatments can improve a person’s well-being and 

ability to manage diabetes. Treatment should be provided 

in accord with current mental health guidelines and in 

collaboration with the diabetes care team.

Kidney disease management [1]

Chronic kidney disease is defined as the persistent (at 

least 3 months), and usually progressive, reduction in 

estimated glomerular filtration rate (eGFR) to less than 

60 mL/min/1.73 m2, and/or albuminuria (a urinary 

albumin-to-creatinine ratio >30/mg/g). Kidney status 

should be annually assessed by a marker of damage, 

“spot” urine albumin-to-creatinine ratio, and an estimate 

of function, the eGFR, calculated from the serum 

creatinine level http://nkdep.nih.gov/professionals/gfr_

calculators/ index.htm. 

Treatment with an ACE inhibitor or an ARB is recommended for patients with diabetes and hypertension and/

or albuminuria greater than 300 mg/day. These drugs may 

also be beneficial in normotensive patients with albuminuria between 30-300 mg/day, but data to support the routine 

use of ACE inhibitors in this setting does not yet exist.

Complications of kidney disease correlate with level of 

kidney function. When the estimated GFR is less than 60 

ml/min per 1.73 m2, screening for anemia, malnutrition, 

and metabolic bone disease is indicated. Early vaccination 

against hepatitis B is indicated in patients likely to progress to end-stage kidney disease. 

Consider referral to a physician experienced in the care of 

kidney disease when there is uncertainty about the etiology of kidney disease (active urine sediment, absence of 

retinopathy, or rapid decline in GFR), difficult management issues, or advanced kidney disease. The threshold 

for referral may vary depending on the frequency with 

which a provider encounters patients with significant 

diabetic kidney disease. Consultation with a nephrologist 

when stage four chronic kidney disease develops has been 

found to reduce cost, improve quality of care, and keep 

people off dialysis longer. 

Nonrenal specialists should educate their patients about 

the progressive nature of diabetic kidney disease; the renal 

preservation benefits of aggressive treatment of blood 

pressure, blood glucose, and hyperlipidemia; and the 

potential need for renal replacement therapy.

Medical nutrition therapy [42] 

Medical nutrition therapy (MNT) is an integral component of diabetes management. MNT is usually provided 

by a registered dietitian who assesses a patient’s nutritional status and collaborates with the patient to develop 

a personal meal plan. People with diabetes should be 

referred for MNT as neededto achieve weight and 

other treatment goals. For most people with diabetes, 

diet composition recommendations include total fat 

about 30 percent of total calories and saturated fat less 

than 7 percent. Intake of trans fat should be minimized. 

Monitoring carbohydrate intake is a key strategy in 

achievingglycemic control, whether by carbohydrate 

counting or experience-based estimation. 

Weight loss is an importantgoal in overweight or obese 

individualswho have type 2 diabetes. Measuring waist 

circumference and the body mass index can help assess 

and monitor the level of adiposity. Heart disease risk 

increases with a waist measurement of over 40 inches 

in men and over 35 inches in women. Weight loss 

requires a reduction in energy intake and is enhanced by 

physical activity. A moderate decrease in caloric balance 

(500–1,000 kcal/day)will result in a slow but progressive 

weight loss (1–2lb/week). For most people, weight loss 

meal plans should supplyat least 1,000–1,200 kcal/day for 

women and 1,200–1,600kcal/day for men.
15 

Neuropathy management [1]

The early recognition and appropriate management of 

neuropathyis important because a number of treatment 

options exist for symptomatic diabetic neuropathy. Most

common among the neuropathies are chronic sensorimotor distal symmetric polyneuropathy (DPN) and

autonomic neuropathy. Up to 50 percent of DPNmay be 

asymptomatic, and patients are at risk of insensate injury

to their feet. Autonomic neuropathy may involve every 

systemin the body and cardiovascular autonomic neuropathy causessubstantial morbidity and mortality. Optimal 

glycemic control may slow progression, butnot reverse, 

neuronal loss. Effective symptomatic treatments are available for some manifestations of DPN and autonomic 

neuropathy.

•	 All patients should be screened for distal symmetric 

polyneuropathy(DPN) at diagnosis and at least annually thereafter, using simple clinical tests. 

•	 Educate all patients about self-care of the feet. For those

with DPN, enhanced foot care education is necessary as 

well as referralfor special footwear. Research indicates 

that patients at high risk of foot ulcers can be identified and taught self-management skills that can prevent 

ulcers and amputations. See Resource section for Feet 

Can Last a Lifetime Kit – a comprehensive kit for 

health care professionals that contains ready-to-use foot 

exam forms, Medicare certification forms for therapeutic footwear, a sample disposable sensory testing monofilament, and reproducible patient education materials.

•	 Screen for signs andsymptoms of autonomic neuropathy at diagnosisof type 2 diabetes and 5 years afterthe 

diagnosis of type 1diabetes. 

•	 Medications for the relief ofspecific symptoms related 

to DPNand autonomic neuropathy are recommended, 

as they improve thequality of life of the patient.

Obesity treatment

Medication therapy for weight management may be 

considered part of the ongoing treatment for all patients 

with diabetes who are overweight or obese. 

Bariatric surgery may be considered in obese (BMI >35) 

patients with diabetes who have not responded to medical 

management. The benefits and risks of bariatric surgery 

vary dependent upon individual circumstance, type of 

surgical procedure, and skill of the surgeon. 

Physical activity 

To improve glycemic control, assist with weight maintenance,and reduce cardiovascular disease risk, adults 

with diabetes, in consultation with their health care 

team, need:

•	 At least 150 min/week of moderate-intensityaerobic 

physical activity (50–70 percent of maximum heart 

rate)

and/or 

•	 Seventy-five to 90 min/week of vigorous aerobic exercise (>70 percent of maximum heart rate) 

Encourage patients to set a modest initial physical activity 

goal. Gradually increase the duration and frequency to30 

to 60 minutes of moderate aerobic activity, 3 to 5 daysper 

week. Activity time can be spread out over each day. 

Adults with diabetes, in the absence of contraindications, 

are advised to perform resistance exercise three times a 

week, targeting all major muscle groups, progressing to 

three sets of 8 to10 repetitions at a weight that cannot be 

liftedmore than 8 to 10 times [43] and to follow guidelines shown at www.health.gov/paguidelines/default.aspx.

Children and adolescents need

•	 Sixty minutes or more of moderate or vigorous intensity aerobic physical activity every day

•	 On at least three days per week, muscle-strengthening 

(e.g., using playground equipment, climbing trees, and 

playing tug-of-war) and bone-strengthening activity 

(e.g., running, jumping rope, basketball, tennis, and 

hopscotch)

To sustain long-term weight loss, adults with diabetes 

need 

•	 At least60 minutes per day of moderate activity such as 

brisk walking, or 30 minutes per day of vigorous activity such as jogging, and 

•	 To be assessed for risk of cardiovascular disease or 

injury, or contraindications for certain types of exercise, 

before beginning a vigorous physical activity program 

[44] 
16 

Retinopathy management

Optimal glycemic and blood pressure control can reduce 

risk of retinopathy or slow its progression. Patients should 

be monitored by an ophthalmologist or optometrist for 

retinopathy through annual dilated eye exams (if normal, 

the eye care specialist may advise an exam every two 

to three years). Most retinal eye disease can be treated 

successfully by laser therapy. Patients with any level of 

macular edema, severe background retinopathy, or any 

proliferative retinopathy should be referred for treatment 

to an ophthalmologist experienced in the care of retinal 

disease. Retinopathy is not a contraindication to low-dose 

aspirin use for CVD prevention.

Self-care behaviors

All people with diabetes need to work with their health 

care team to develop a personal food and physical activity 

plan and to attend to other self-care behaviors. Prevention 

of long-term complications is enhanced if people with 

diabetes practice the following healthy self-care behaviors: 

•	 Eat a variety of foods high in fiber, low in sodium and 

sugar, and low in saturated and trans fats.

•	 Reduce food portion sizes to help with weight loss, if 

appropriate. 

•	 Get 30 to 60 minutes of moderate–intensity physical 

activity most days of the week. This could be brisk 

walking, yard work, and actively playing with children, 

such as riding bicycles or playing soccer.

•	 Take prescribed medications, including low-dose aspirin, even when feeling good, with no symptoms.

•	 Check their blood glucose as advised and use the results 

to manage blood glucose.

•	 Check their feet daily and contact their doctor if a sore 

does not begin to heal after one day. 

•	 Brush their teeth twice a day and floss once a day.

•	 Make regular visits to their health care team for diabetes, foot, dental, and eye care. Contact their health care 

team about any foot, dental, or eye problems. 

•	 Seek help to stop smoking.

•	 Seek help for stress, diabetes-related distress, and 

depression.

Smoking cessation

Smoking more than doubles the risk for cardiovascular 

disease in people with diabetes. People who stop smoking 

greatly reduce their risk of premature death. Medications, 

counseling, and smoking cessation programs increase the 

chances of success, as do telephone help lines. Additional 

effective therapies include nicotine replacement products (e.g., gum, inhaler, and patch) www.smokefree.gov; 

1-800-QUITNOW (1-800-784-8669) routes callers to 

their state’s smoking cessation quit line or to the National 

Cancer Institute’s quit line. 

Vaccinations 

•	 Provide influenza (annually). 

•	 Provide pneumoccal (usually only once, repeat if over 

64 or immunocompromised and the last vaccination 

was more than 5 years ago). 

For NDEP resources for people 

with diabetes see page 22. 
17 

Principle 5: 

Consider the Needs of Special Populations — 

Children, Women of Childbearing Age, 

Older Adults, and High-Risk Racial and 

Ethnic Groups

Certain populations — children, women of childbearing age, the elderly, and different racial and ethnic 

groups — have special diabetes management issues that need to be addressed.

Diabetes in children 

Diabetes is one of the most common chronic conditions in 

school-age children in the United States. About 183,300 

youth under 20 years of age have diabetes – 0.2 percent 

of all in this age group. [2] Type 1 diabetes accounts for 

most cases. Type 2 becomes increasingly common after 

age 10, with higher rates in minority groups than in nonHispanic whites. The highest rates are seen in American 

Indian youth. As more children and teens become overweight, a hybrid form of diabetes may become more 

common. Youth with hybrid diabetes are likely to have 

both insulin resistance that is associated with obesity and 

type 2 diabetes, and antibodies against the pancreatic islet 

cells that are associated with autoimmunity and type 1 

diabetes. In addition to lifestyle changes, treatment may 

involve both insulin therapy and oral glucose-lowering 

medications. 

The treatment of children with diabetes differs from that 

of adults since attention must be paid to physical growth 

and maturation, decreased insulin sensitivity during mid 

to late puberty, ability to provide self-care, the need to 

provide care at school, neurological vulnerability to hypoglycemia in young children, and the eventual need to 

transition to adult care. Cardiovascular disease risk factors 

have been observed among some youth with both type 

1 and type 2 diabetes. Evidence indicates that primary 

prevention of cardiovascular disease should begin in 

childhood. [45] 

Management and education

Education of the family about their child’s diabetes 

management is essential. The family and their diabetes 

care team need to develop individualized blood glucose 

targets, types and doses of insulin, frequency of blood 

glucose testing, when to test for ketones, insulin delivery 

systems, and details of dietary management. Other essential management tasks include recognition of high and 

low blood glucose, confirmation by blood glucose testing 

when possible, and, where necessary, prompt administration of glucose to treat hypoglycemia (or glucagon for 

severe hypoglycemia). 

Most young people can learn to adjust their insulin doses 

according to activity and eating patterns — rather than 

follow a rigid meal plan and insulin dose schedule. Insulin 

may be injected three or more times a day or may be 

given by an insulin pump that provides continuous subcutaneous infusion of basal and meal-related doses of insulin. Children may learn to vary their carbohydrate intake 

and calculate the proper insulin dose by using an insulin/

carbohydrate ratio. 

Diabetes at school

The health care team needs to work with the school nurse 

to provide a written diabetes management plan for every 

student with diabetes. The plan must be conveyed to the 

school nurse or trained school personnel who will work 

with students and parents to implement the plan in the 

school setting. Children with diabetes should be able to 

participate fully in all sports and physical education activities and to attend field trips. (See Resource section for 

Helping the Student with Diabetes Succeed: A Guide for 

School Personnel.)

Psychosocial issues

Learning to cope with the disease often causes 

emotional and behavioral challenges, sometimes leading to depression or eating disorders. A social worker or 

psychologist may help young people and their families 

learn to adjust to the lifestyle changes needed for effective diabetes management. As teenagers transition into 
18 

adulthood and become more independent, the health 

care team needs to help them maintain effective diabetes 

self-management skills. 

Diabetes in women of childbearing age

Major congenital malformations remain the leading cause 

of mortality and serious morbidity in infants of mothers 

with pre-existing type 1 and type 2 diabetes. The risk of 

malformations increases continuously with increasing 

maternal glycemia during the first six to eight weeks of 

gestation. To minimize the occurrence of these devastating malformations, all women with diabetes who have 

childbearing potential should be counseled about:

•	 The risk of malformations associated with unplanned 

pregnancies and poor diabetes control and

•	 Use of effective contraception at all times, unless their 

diabetes is well managed and they are actively trying to 

conceive [1]

Because of the risk of gestational diabetes to the mother 

and neonate, screening, diagnosis, and effective treatment is necessary. Gestational diabetes increases infant 

macrosomia and adverse perinatal outcomes including 

caesarean section, spontaneous preterm delivery, shoulder 

dystocia or birth injury, neonatalhypoglycemia, and need

for intensive neonatal care. [46] Women with a history 

of gestational diabetes are at lifelong increased risk for 

diabetes. The child of a diabetes pregnancy is at increased 

risk for obesity and diabetes later in life. See Table 5 for 

screening recommendations for women with history of 

gestational diabetes.

Women with diabetes or history of gestational diabetes 

who are planning pregnancy need to be seen frequently 

by a skilled multidisciplinary team experienced in the 

management of diabetes, before and during pregnancy. 

The management team will need to maintain stable blood 

glucose values close to normal, as well as identify and 

manage any existing long-term diabetic complications.

Diabetes in older adults

At least 20 percent of people over the age of 65 have 

diabetes. Older people with diabetes have higher rates 

of premature death, functional disability, and coexisting 

illnesses such as hypertension, coronary heart disease, 

and stroke than those without diabetes. Older adults with 

diabetes are also at greater risk than otherolder adults for 

several common geriatric syndromes, such aspolypharmacy, depression, cognitive impairment, urinary incontinence,injurious falls, and persistent pain. While glycemic 

control has not been proven to reduce CVD in older 

patients, there is strong evidence for lipid and blood pressure management. 

Management goals therefore must be individualized. 

Older adults who are free of cardiovascular disease, 

active, cognitively intact, and willing to participate in selfmanagement should be encouraged to do so and should 

be treated using the same goals for younger adults with 

diabetes. Older adults can be treated with the same medications as younger people, but special care is required in 

prescribing and monitoring therapy. Medications should 

be started at the lowest dose and titrated up gradually until 

targets are reached or side effects develop. 

The family needs education to help older family members 

achieve their diabetes management goals and access 

useful resources.

Diabetes in high-risk racial groups

A number of racial and ethnic populations are disproportionately affected by diabetes. Compared to non-Hispanic 

white adults, African Americans, Hispanic/Latino 

Americans, and Asian Americans and Pacific Islanders 

are almost two times more likely to have diabetes. 

American Indians and Alaska Natives are more than two 

times as likely to have diabetes. 

To provide optimal diabetes care, the health care team 

needs to learn how patients view and treat diabetes within 

their respective cultures. A practical approach to avoid 

stereotyping involves treating each patient encounter 

as unique and asking questions that elicit the patient’s 

perspective on diagnosis and management such as “What 

is hardest for you about having diabetes?” or “Do you 

have any religious or family customs that affect how you 

care for your health?” This patient-centered approach 

enables collaboration and negotiation between the patient 

and health care team to develop and implement an effective diabetes management plan that addresses individual 

needs and customs. It is important that appropriate and 

culturally sensitive diabetes education materials are 

provided to all patients.

It is important to use appropriate A1C assay in people 

with hemoglobinopathy. See Sickle Cell Trait and Other 

Hemoglobinopathies and Diabetes: Important Information 

for Physician. 

www.diabetes.niddk.nih.gov/dm/pubs/hemovari-A1C/. 

Note. The Office of Minority Health provides resources to 

protect the health of racial and ethnic minority populations 

and eliminate health disparities: www.omhrc.gov.
19 

Principle 6: 

Provide Regular Assessments to Monitor 

Treatment Effectiveness and to Detect 

Diabetes Complications

People with diabetes should have regular exams to monitor the effects of treatment, assess disease 

progression, and help find and treat diabetes complications. Assessment should be made on a regular 

basis using current, reliable methods. All diabetes complications have effective treatments. 

Regular monitoring of diabetes management enables the 

diabetes team to assess achievement of treatment goals 

and to adjust therapy as necessary. Regular checking for 

long-term complications can help detect problems at a 

time when they can be treated and managed successfully. 

The physical examination, laboratory tests, and other 

assessments that the team conducts to monitor management and to identify complications early should be 

performed during routine diabetes visits, and at quarterly 

and annual visits. 

At each diabetes visit: 

•	 Measure weight, blood pressure, and calculate BMI.

•	 Inspect feet for lesions or abnormalities if one or more 

high-risk foot conditions are present. 

•	 Review self-monitoring glucose record.

•	 Review/adjust medications to control glucose, lipids, 

blood pressure. Include regular use of low dose aspirin 

(if there are not contraindications) for cardiovascular 

disease prevention, as appropriate.

•	 Review self-management skills, progress toward behavior change goals, dietary needs, and physical activity as 

indicated.

•	 Assess for coping, depression, or other mood disorder.

•	 Counsel on smoking cessation and alcohol use.

•	 Review interventions for weight loss. 

Quarterly:

•	 Obtain A1C in patients whose therapy has changed or 

who are not meeting glycemic goals (twice a year if at 

goal with stable glycemia). 

Annually: 

•	 Obtain fasting lipid profile (every two years if patient 

has low-risk lipid values).

•	 Obtain serum creatinine to estimate glomerular filtration rate and stage the level of chronic kidney disease.

•	 Perform urine test for albumin-to-creatinine ratio in 

patients with type 1 diabetes more than five years and 

in all patients with type 2 diabetes.

•	 Refer for dilated eye exam by an ophthalmologist or 

optometrist to detect retinal and other eye complications. If normal and the patient is not at high risk, the 

eye care specialist may advise an exam every two to 

three years.

•	 Perform comprehensive foot exam to check circulation, 

sensation, lesions, or changes in shape, and identify 

high-risk feet.

•	 Refer for dental/oral exam at least once a year to 

prevent periodontal disease, mouth infections, and loss 

of teeth.

•	 Administer influenza vaccination.

•	 Review need for other preventive care or treatment.

Lifetime:

•	 Administer pneumococcal vaccination (repeat if over 

64 or immunocompromised and last vaccination was 

more than 5 years ago). 
20 
21 

Resources

All NDEP materials are available free of charge.

To order, visit www.YourDiabetesInfo.org or call 

1-888-693-NDEP (6337). Materials may be downloaded, 

reproduced, and distributed without copyright restrictions. 

Organization logos and contact information may be added 

to NDEP materials for personal printing and distribution 

needs. 

Campaigns

Based on these guiding principles for diabetes care, 

NDEP promotes early and intensive diabetes management 

and prevention through widespread education campaigns 

and community outreach programs. The Control Your 

Diabetes. For Life. campaign promotes optimal comprehensive diabetes management. The Small Steps. Big 

Rewards. Prevent type 2 Diabetes. campaign addresses 

the need to prevent type 2 diabetes. 

Materials for health care professionals — primary 

care providers, diabetes educators, dietitians, nurses, pharmacists, and specialists, among many others, as well as 

school personnel — all of whom need to be engaged in 

caring for people with or at risk for diabetes. Materials 

include:

Presentation slides

o Diabetes: The Science of Control; Diabetes: The 

Science of Prevention

Slides sets present current information about diabetes 

prevalence and incidence in the United States, and 

diabetes management and prevention. 

Quick reference materials 

o Diabetes Numbers At-a-Glance Reference Card 

A pocket guide provides a list of current recommendations to diagnose and manage pre-diabetes and 

diabetes. 

Diabetes management resources

o Feet Can Last a Lifetime Kit 

A comprehensive foot care guide provides tools and 

techniques to implement effective clinical procedures 

and preventive foot care for people with diabetes. 

o Helping the Student with Diabetes Succeed. 

A Guide for School Personnel 

A school guide helps the student, school personnel, 

parents, and the health care team work together to 

provide optimal diabetes management in the school 

setting. 

o Si Tiene Diabetes, Cuide Su Corazón (If You 

Have Diabetes, Take Care of Your Heart) 

A bilingual presentation flipchart (in Spanish and 

English) helps educate Hispanic/Latino Americans 

about the link between diabetes and heart disease. 

o Team Care: Comprehensive Lifetime 

Management for Diabetes 

A team care booklet helps implement multidisciplinary team care for people with diabetes in various 

settings. 

o Working Together to Manage Diabetes: Diabetes 

Medications Supplement 

A detailed reference booklet profiles medications 

used to manage blood glucose, blood pressure, and 

cholesterol. 

o Working Together to Manage Diabetes: A Guide 

for Pharmacists, Podiatrists, Optometrists, and 

Dental Professionals 

An interdisciplinary primer focuses on diabetesrelated conditions affecting the foot, eye, and mouth, 

as well as the issues related to medication management. 

Diabetes prevention resources

o Small Steps. Big Rewards. Your GAME PLAN 

to Prevent Type 2 Diabetes: Health Care Provider 

Toolkit 

A toolkit contains a decision pathway to diagnose and 

treat pre-diabetes, proven strategies to counsel and 

motivate patients, an office poster, and copier-ready 

patient education materials. 

o The Road to Health Toolkit 

A multi-component primary prevention toolkit 

provides several tools to promote type 2 diabetes 

prevention through lifestyle change education that 

focuses on healthy eating and increased physical 

activity. CD/DVDs and training guide and video 

included. 
22 

Materials for health care professionals to provide 

to their patients — NDEP work group members and 

partners, as well as focus group findings, help NDEP 

develop appropriate, culturally sensitive patient education 

materials and community partnership guides. Many of 

these materials help people learn about the seriousness of 

diabetes, ways to prevent and manage diabetes, and the 

resulting benefits. 

Materials have been adapted for 21 different audiences: 

African American, American Indian and Alaska Native, 

15 Asian and Pacific Islander audiences (in their 

languages), children and adolescents, older adults, Spanish 

speaking populations, and women with a history of 

gestational diabetes. 

o 4 Steps to Control Your Diabetes for Life, an easy 

to read booklet, is available in English and Spanish. It 

condenses these guiding principles and helps people 

with diabetes make informed decisions about their 

diabetes care. 

o The Small Steps. Big Rewards. Your GAME PLAN 

to Prevent Type 2 Diabetes is an easy-to-read toolkit in 

English and — coming soon in Spanish — that helps 

people at risk take steps to prevent diabetes. Many tip 

sheets, tailored for multicultural audiences, older adults, 

and women with a history of gestational diabetes, help 

motivate patients to lose weight and increase their 

physical activity — small steps needed to achieve the big 

reward of preventing type 2 diabetes.

For more information about NDEP’s partners, messages, 

campaigns, and materials, visit www.YourDiabetesInfo.

org. 

Additional websites

www.BetterDiabetesCare.nih.gov — provides tools and 

resources to help health care professionals identify and 

implement important changes in the delivery of diabetes 

care to improve patient outcomes. 

www.DiabetesAtWork.org — provides tools and 

resources to help businesses and managed care organizations reduce diabetes risk factors in employees, assess the 

impact of diabetes in the workplace, and help employees 

manage diabetes and lower heart disease risk. 

For more information on diabetes and related topics, 

visit the National Institute of Diabetes and Digestive and 

Kidney Diseases at www.niddk.nih.gov.
23 

References

1. American Diabetes Association: Standards of medical 

care in diabetes—2009. Diabetes Care 2009; 32(Suppl 1): 

S13-61.

2. Centers for Disease Control and Prevention: National 

diabetes fact sheet: general information and national 

estimates on diabetes in the United States, 2007. 2008.

3. National Heart Lung and Blood Institute: Practical 

guide to the identification, evaluation and treatment of 

overweight and obesity in adults. Bethesda, MD: National 

Institutes of Health, 2000.

4. American Association of Clinical Endocrinologists 

medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract 2007; 13(Suppl 1): 

1-68.

5. United States Preventive Services Task Force: Guide 

to Clinical Preventive Services. 2nd ed. Alexandria, VA: 

Office of Disease Prevention and Health Promotion, 1996.

6. Metzger BE, Buchanan TA, Coustan DR, et al.: 

Summary and Recommendations of the Fifth International 

Workshop-Conference on Gestational Diabetes Mellitus. 

Diabetes Care 2007; 30(S2): S251-S260.

7. Knowler WC, Barrett-Connor E, Fowler SE, et al.: 

Reduction in the incidence of type 2 diabetes with lifestyle 

intervention or metformin. N Engl J Med 2002; 346(6): 

393-403.

8. Pettitt DJ, Knowler WC: Long-term effects of the intrauterine environment, birth weight, and breast-feeding in 

Pima Indians. Diabetes Care 1998; 21(Suppl 2): B138-41.

9. Nathan DM, Davidson MB, DeFronzo RA, et al.: 

Impaired fasting glucose and impaired glucose tolerance: 

implications for care. Diabetes Care 2007; 30(3): 753-9.

10. National Heart Lung and Blood Institute/National 

Institute for Diabetes and Digestive and Kidney Diseases: 

Clinical guidelines on the identification, evaluation, and 

treatment of overweight and obesity in adults: the evidence 

report. Bethesda, MD: National Institutes of Health, 1998.

11. Inge TH, Krebs NF, Garcia VF, et al.: Bariatric 

surgery for severely overweight adolescents: concerns and 

recommendations. Pediatrics 2004; 114(1): 217-23.

12. Snow V, Barry P, Fitterman N, Qaseem A, Weiss 

K: Pharmacologic and surgical management of obesity 

in primary care: a clinical practice guideline from the 

American College of Physicians. Ann Intern Med 2005; 

142(7): 525-31.

13. Funnell MM, Brown TL, Childs BP, et al.: National 

standards for diabetes self-management education. 

Diabetes Care 2007; 30(6): 1630-7.

14. Fisher EB, Brownson CA, O’Toole ML, et al.: The 

Robert Wood Johnson Foundation Diabetes Initiative: 

demonstration projects emphasizing self-management. 

Diabetes Educ 2007; 33(1): 83-4, 86-8, 91-2, passim.

15. Diabetes Control and Complications Trial Research 

Group: The effect of intensive treatment of diabetes on the 

development and progression of long-term complications 

in insulin-dependent diabetes mellitus. N Eng J Med 1993; 

329(14): 977-86.

16. Nathan DM, Cleary PA, Backlund JY, et al.: 

Intensive diabetes treatment and cardiovascular disease 

in patients with type 1 diabetes. N Engl J Med 2005; 

353(25): 2643-53.

17. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil 

HA: 10-Year Follow-up of Intensive Glucose Control in 

Type 2 Diabetes. N Engl J Med 2008; 359(15): 1577-89.

18. Gerstein HC, Miller ME, Byington RP, et al.: Effects 

of intensive glucose lowering in type 2 diabetes. N Engl J 

Med 2008; 358(24): 2545-59.

19. Patel A, MacMahon S, Chalmers J, et al.: Intensive 

blood glucose control and vascular outcomes in patients 

with type 2 diabetes. N Engl J Med 2008; 358(24): 

2560-72.

20. Duckworth W, Abraira C, Moritz T, et al.: Glucose 

control and vascular complications in veterans with type 2 

diabetes. N Engl J Med 2009; 360(2): 129-39.

21. UK Prospective Diabetes Study (UKPDS) Group: 

Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: 

UKPDS 38. UK Prospective Diabetes Study Group. BMJ 

1998; 317(7160): 703-13.

22. Holman RR, Paul SK, Bethel MA, Neil HA, Matthews 

DR: Long-Term Follow-up after Tight Control of Blood 

Pressure in Type 2 Diabetes. N Engl J Med 2008.

23. Hansson L, Zanchetti A, Carruthers SG, et al.: Effects 

of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the 

Hypertension Optimal Treatment (HOT) randomised trial. 

HOT Study Group. Lancet 1998; 351(9118): 1755-62.

24. Kostis JB, Wilson AC, Freudenberger RS, Cosgrove 

NM, Pressel SL, Davis BR: Long-term effect of diureticbased therapy on fatal outcomes in subjects with isolated 

systolic hypertension with and without diabetes. Am J 

Cardiol 2005; 95(1): 29-35.

25. Heart Outcomes Prevention Evaluation Study 

Investigators: Effects of ramipril on cardiovascular and 

microvascular outcomes in people with diabetes mellitus: 

results of the HOPE study and the MICRO-HOPE 

substudy. Lancet 2000; 355: 253-9.
24 

26. Niskanen L, Hedner T, Hansson L, Lanke J, Niklason 

A: Reduced cardiovascular morbidity and mortality in 

hypertensive diabetic patients on first-line therapy with 

an ACE inhibitor compared with a diuretic/beta-blockerbased treatment regimen: a subanalysis of the Captopril 

Prevention Project. Diabetes Care 2001; 24(12): 2091-6.

27. Nielsen FS, Rossing P, Gall MA, Skott P, Smidt UM, 

Parving HH: Impact of lisinopril and atenolol on kidney 

function in hypertensive NIDDM subjects with diabetic 

nephropathy. Diabetes 1994; 43(9): 1108-13.

28. Patel A, MacMahon S, Chalmers J, et al.: Effects of 

a fixed combination of perindopril and indapamide on 

macrovascular and microvascular outcomes in patients 

with type 2 diabetes mellitus (the ADVANCE trial): a 

randomised controlled trial. Lancet 2007; 370(9590): 

829-40.

29. American Diabetes Association: Management of 

dyslipidemia in adults with diabetes. Diabetes Care 2000; 

23(Suppl.1): S57-S60.

30. Goldberg RB, Mellies MJ, Sacks FM, et al.: 

Cardiovascular events and their reduction with pravastatin 

in diabetic and glucose-intolerant myocardial infarction 

survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial. 

The Care Investigators. Circulation 1998; 98(23): 2513-9.

31. Sacks FM, Pfeffer MA, Moye LA, et al.: The effect of 

pravastatin on coronary events after myocardial infarction 

in patients with average cholesterol levels. Cholesterol and 

Recurrent Events Trial investigators. N Engl J Med 1996; 

335(14): 1001-9.

32. Haffner SM, Alexander CM, Cook TJ, et al.: Reduced 

coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose 

levels: subgroup analyses in the Scandinavian Simvastatin 

Survival Study. Arch Intern Med 1999; 159(22): 2661-7.

33. Colhoun HM, Betteridge DJ, Durrington PN, et al.: 

Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin 

Diabetes Study (CARDS): multicentre randomised 

placebo-controlled trial. Lancet 2004; 364(9435): 685-96.

34. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, 

Pedersen O: Multifactorial intervention and cardiovascular 

disease in patients with type 2 diabetes. N Engl J Med 

2003; 348(5): 383-93.

35. Gaede P, Lund-Andersen H, Parving HH, Pedersen O: 

Effect of a multifactorial intervention on mortality in type 

2 diabetes. N Engl J Med 2008; 358(6): 580-91.

36. Pi-Sunyer X, Blackburn G, Brancati FL, et al.: 

Reduction in weight and cardiovascular disease risk 

factors in individuals with type 2 diabetes: one-year results 

of the look AHEAD trial. Diabetes Care 2007; 30(6): 

1374-83.

37. Skyler JS, Bergenstal R, Bonow RO, et al.: Intensive 

glycemic control and the prevention of cardiovascular 

events: implications of the ACCORD, ADVANCE, and 

VA diabetes trials: a position statement of the American 

Diabetes Association and a scientific statement of the 

American College of Cardiology Foundation and the 

American Heart Association. Diabetes Care 2009; 32(1): 

187-92.

38. A comprehensive assessment of North American and 

United Kingdom glycemic control guidelines. Ann Intern 

Med 2007; 147(6): 417-22 &152.

39. Nathan DM, Buse JB, Davidson MB, et al.: 

Management of hyperglycemia in type 2 diabetes: a 

consensus algorithm for the initiation and adjustment 

of therapy: a consensus statement from the American 

Diabetes Association and the European Association for 

the Study of Diabetes. Diabetes Care 2008; 31(12): 1-11.

40. Nathan DM, Kuenen J, Borg R, et al.: Translating 

the A1C assay into estimated average glucose values. 

Diabetes Care 2008; 31(8): 1473-1478.

41. Bolen S, Feldman L, Vassy J, et al.: Systematic 

review: comparative effectiveness and safety of oral 

medications for type 2 diabetes mellitus. Ann Intern Med 

2007; 147(6): 386-99.

42. Bantle JP, Wylie-Rosett J, Albright AL, et al.: 

Nutrition recommendations and interventions for 

diabetes: a position statement of the American Diabetes 

Association. Diabetes Care 2008; 31(Suppl 1): S61-78.

43. American Diabetes Association: Clinical Practice 

Recommendations -Standards of Medical Care in 

Diabetes. Diabetes Care 2007; 30(Suppl. 1): S4-S41.

44. Sigal RJ, Kenny GP, Wasserman DH, CastanedaSceppa C, White RD: Physical activity/exercise and type 

2 diabetes: a consensus statement from the American 

Diabetes Association. Diabetes Care 2006; 29(6): 1433-8.

45. Rodriguez BL, Fujimoto WY, Mayer-Davis EJ, et al.: 

Prevalence of cardiovascular disease risk factors in U.S. 

children and adolescents with diabetes: the SEARCH 

for diabetes in youth study. Diabetes Care 2006; 29(8): 

1891-6.

46. Metzger BE, Lowe LP, Dyer AR, et al.: 

Hyperglycemia and adverse pregnancy outcomes. N Engl 

J Med 2008; 358(19): 1991-2002.
The U.S. Department of Health and Human Services’ National Diabetes Education Program is 

jointly sponsored by the National Institutes of Heath and the Centers for Disease Control and Prevention 

with the support of more than 200 partner organizations.

www.YourDiabetesInfo.org 1-888-693-NDEP (6337) TTY: 1-866-569-1162

NIH Publication No. 09-4343 NDEP-16 Revised April 2009