NATIONAL 

DIABETES

E D U C AT I O N

PROGR AM 

Guiding Principles

for Diabetes Care:

For Health Care

Providers
The National Diabetes Education Program (NDEP) has developed these Guiding Principles forDiabetes

Care to help the health care team manage the disease effectively. The principles outline seven essential

components of quality diabetes care that form the basis of NDEP’s public and professional awareness 

programs. Payers of health care, managed care organizations, and large employers can use them to 

establish diabetes care principles, to assess quality, and to assure quality diabetes care and treatment 

service options in health plans. 

The NDEP believes that people with diabetes and their families should actively participate with their

health care team to plan and implement their care. While these principles serve as a guide for discussing

diabetes management, each person with diabetes and his or her health care team determine the specific

management plan.

NDEP EXECUTIVE COMMITTEE 

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

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

Lawrence Blonde, M.D., F.A.C.P.

Judith E. Fradkin, M.D.

Frank Vinicor, M.D., M.P.H.

NATIONAL DIABETES EDUCATION PROGRAM

STEERING COMMITTEE MEMBERS

American Academy of Family Physicians

American Academy of Nurse Practitioners

American Academy of Physician Assistants

American Association of Clinical Endocrinologists

American Association of Diabetes Educators

American Association of Health Plans

American College of Physicians

American Diabetes Association

American Dietetic Association 

American Health Quality Association

American Pharmacists Association

Association of American Indian Physicians

Association of Asian Pacific Community

Health Organizations

Centers for Disease Control and Prevention/Division 

of Diabetes Translation 

Diabetes Council, State Diabetes Prevention 

and Control Programs

Diabetes Research and Training Centers

Endocrine Society

Ethiopian Community Development Council

Juvenile Diabetes Research Foundation International

Lions Clubs International

Managed Health Care Association

National Alliance for Hispanic Health

National Asian Women’s Health Organization

National Hispanic Medical Association

National Institutes of Health/National Institute of

Diabetes and Digestive and Kidney Diseases 

National Urban League

The Links, Inc.

FEDERAL LIAISONS TO THE 

NDEP STEERING COMMITTEE

Agency for Healthcare Research and Quality

Health Resources and Service Administration/Bureau 

of Primary Health Care

Centers for Medicare and Medicaid Services

Indian Health Service

Office of Minority Health

U.S. Administration on Aging

U.S. Department of Agriculture

U.S. Veterans Administration Health Care System

NDEP STAFF 

TaWanna Berry, M.A.

Joanne Gallivan, M.S., R.D. 

Sabrina Harper, M.S.

Jane Kelly, M.D. 

Saul Malozowski, M.D., Ph.D., M.B.A. 

Elizabeth Warren-Boulton, R.N., M.S.N.

The National Diabetes Education Program is a joint program of the National Institutes of Health 

and the Centers for Disease Control and Prevention.

www.ndep.nih.gov Phone: 1-800-438-5383

Publication No. 99-4343 April 2004
Introduction 

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

caused by diabetes and its complications through programs that increase awareness of the seriousness of

the disease and the value of its treatment and prevention. These Guiding Principles for Diabetes Care for

health care providers are evidence-based and describe the essential components of quality diabetes care. 

People with diabetes and their health care team need to have ongoing discussions about what care is best

for each individual and why. Many health care providers make up the team to care for people with diabetes,

including physicians, diabetes educators, nurses, dietitians, pharmacists, social and mental health workers,

eye specialists, foot specialists, and dentists. 

Ongoing, comprehensive diabetes care can prevent or control diabetes-related macrovascular complications

(heart disease, stroke, and circulatory problems) and microvascular complications (blindness, amputations,

and end-stage renal disease). With proper education and self-care, people with diabetes should expect to

lead long, active, and productive lives.

PRINCIPLE 1: 

Identify People with Pre-Diabetes 

and Undiagnosed 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. More than 18 million Americans have diabetes; 

5.2 million of whom have undiagnosed type 2 diabetes. More than 40 percent of U.S. adults ages 

40-74—or 41 million people—currently have pre-diabetes, placing them at increased risk for 

cardiovascular disease and type 2 diabetes.

DEFINITIONS Pre-diabetes is the term that has been adopted to

describe those states that occur when a person’s

blood glucose levels are higher than normal but 

not high enough for a diagnosis of diabetes. People

with pre-diabetes have impaired fasting glucose

(IFG) or impaired glucose tolerance (IGT) and 

are at increased risk for type 2 diabetes. 

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. The diagnosing health care provider

should use clinical judgment to decide which test to

use. A diagnosis of diabetes should be confirmed on

another day.

Fasting plasma glucose (FPG)

100–125 mg/dl after an 

overnight fast

2-hr post 75g glucose challenge 

140–199 mg/dl

Random plasma glucose>200 mg/dl

with symptoms (polyuria, polydypsia,

and unexplained weight loss) or

FPG>126 mg/dl or

2-hr plasma glucose>200 mg/dl post

75g glucose challenge

Impaired

Fasting

Glucose

Impaired

Glucose

Tolerance

Diabetes

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PRINCIPLE 2: 

Provide Ongoing, 

Patient-Centered Care

People with diabetes need to be part of a health care delivery system that provides high quality,

patient-centered care on an ongoing basis. This approach ensures that timely changes in their 

treatment are made to achieve optimal control of the disease.

People with diabetes need ongoing care in a patientcentered, supportive, and positive environment,

without barriers to obtaining care. The health 

care team should include a provider responsible 

for ongoing care and skilled in its delivery, with

access to other physician specialists and health 

care professionals. 

Certain high risk groups—ethnic populations, 

children, pregnant women, and the elderly—have

special needs that should be addressed. People with

diabetes also need support from their family,

friends, and co-workers. Financial resources are

needed for ongoing education, durable equipment,

supplies, medications, and insulin. Discrimination

against employment, licensing, and obtaining 

insurance should be avoided. 

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RISK FACTORS FOR PRE-DIABETES 

AND DIABETES INCLUDE:

Age— 45 and older

PLUS

Overweight— body mass index ≥25 kg/m2 (≥23 if

Asian American or ≥26 if Pacific Islander) 

In addition to age and weight, these factors 

increase risk:

Ethnicity—African American, American Indian,

Asian American, Hispanic and Latino American, or

Pacific Islander heritage

Family history—have a first-degree relative 

with diabetes

History of gestational diabetes or gave birth to a

baby weighing > 9 lbs 

Hypertension—blood pressure >140/90

Abnormal lipid levels—HDL cholesterol level

< 40mg/dl for men and < 50mg/dl for women;

triglyceride level >250 mg/dl

IGT or IFG on previous testing

Polycystic ovary syndrome or acanthosis nigricans 

History of vascular disease

Inactive lifestyle—exercises less than three 

times a week

Testing is strongly recommended when a person is

age 45 or older and overweight.

Consider testing when a person is:

• 45 or older or

• younger than 45, overweight, with one or 

more risk factors.

If results are normal, consider testing at 3-year

intervals.

Early identification of pre-diabetes and diabetes may

reduce or prevent the development of long-term

complications before the person has been diagnosed.

The diagnosis of pre-diabetes and diabetes should 

be clear, based on accepted guidelines for FPG or

IGT values. 

Terms such as “a touch of diabetes” or “sugar’s a

little high” are confusing and should not be used.

People with diabetes should know what type of 

diabetes they have. 
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PRINCIPLE 3: 

Offer Diabetes Education

People with diabetes and their family members need accurate information and 

education for diabetes self-care. 

Health care providers are responsible for offering

diabetes education that addresses the medical 

and emotional needs of the individual patient.

Education enables people with diabetes to 

participate more actively in their treatment 

and in prevention of complications. 

Diabetes education is a continuous process. It should

begin with the essential elements of self-care and

include instruction on following the prescribed 

medical regimen. Over time, the instruction should

become a dialogue that defines and addresses the

ongoing needs of the individual and his or her family. 

People with pre-diabetes and diabetes need 

opportunities to acquire the knowledge and skills

that enable and empower them to perform effective

self-care. Certified diabetes educators and dietitians

can help provide these services. It is important to

enlist family members and others who provide 

support to help the patient achieve a greater 

measure of self-care and quality of life. 

PRINCIPLE 4: 

Treat Diabetes Comprehensively

A1C, blood pressure, and cholesterol, the “ABCs of diabetes,” should be kept as near to normal as is

safely possible. The target values should be based on an overall assessment of the person’s health. 

A primary goal of diabetes treatment is the control

of hyperglycemia by a variety of methods. It is well

known that over many years hyperglycemia causes

long-term complications of diabetes. The risk of eye

disease (retinopathy), kidney disease (nephropathy)

and nerve damage (neuropathy) is strongly linked

with high blood glucose levels. 

Scientific evidence shows that controlling blood 

glucose, blood pressure, and cholesterol—the

“ABCs of diabetes”—can lower the risk for 

cardiovascular disease (hardening of the arteries,

heart attack, stroke, and circulatory problems). 

All people with diabetes should follow a healthy

food and physical activity plan. In type 1 diabetes,

insulin is always required, combined with a welldefined treatment plan. In some people with type 2

diabetes, following a healthy food and exercise plan

initially achieves diabetes control, but most will

eventually require the addition of oral medications

and/or insulin. 

The exact methods of treatment—diet, exercise, 

oral antidiabetic agents and/or insulin—should be

tailored to individual needs. People with diabetes

should participate in the decision making process,

with options, goals, and targets clearly stated. 

A1C <7 percent

Blood Pressure <130/80

Cholesterol (LDL) <100 mg/dl

Target ABC Values
PRINCIPLE 5: 

Monitor Blood Glucose Control 

using the A1C Test

A1C and blood glucose should be measured on a routine basis using current, reliable methods. 

A1C is the principal method for monitoring glucose

control. The NDEP and it partners have adopted

the simple name “A1C” when referring to the

hemoglobin A1c test. It is a standardized blood 

test that indicates the average blood glucose over

the previous 8 to 12 weeks. Since most long-term

complications of diabetes are related to A1C, 

measuring it should be a regular part of assessing

diabetes care. People with diabetes should know

their own A1C and whether they are reaching 

their target. 

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. 

Routine self-monitoring of blood glucose is a 

successful approach in self-management of diabetes

because it provides a picture of the immediate

blood glucose level. Individual circumstances 

will define how often self-monitoring is used, the

specific approach, and the methods of recording

and reporting results. People with diabetes need

access to self-management tools, including blood

glucose meters and strips. 

PRINCIPLE 6: 

Prevent Long-term Diabetes Problems

Comprehensive care can significantly lower risk for long-term diabetes problems.

For those with pre-diabetes, modest weight loss (5

to 7 percent) through regular physical activity and a

low fat, low calorie diet can prevent or delay the

onset of diabetes. Preventing or delaying the onset

of diabetes also is likely to prevent or delay the

onset of diabetes complications. 

For those with diabetes, controlling blood glucose 

is one important way to prevent complications. For

every 1 percent lowering of the A1C toward normal,

there is up to a 37 percent reduction in risk for

microvascular complications in people with type 1

and type 2 diabetes. 

To reduce the risk of cardiovascular disease, 

other important risk factors must be controlled—

hypertension, abnormal blood fats (especially high

LDL-cholesterol, high total cholesterol, and low

HDL-cholesterol), and smoking. Routine 

measurement and management of these risk factors

are essential for good diabetes care. In people with

diabetes, the cardiovascular benefits of blood 

pressure and lipid control are equal to or greater

than the benefits to people without diabetes.

For both types of diabetes, preventing long-term

complications is enhanced by practicing the 

following healthy self-care behaviors:

• Eating healthy foods

• Controlling portion sizes

• Getting daily physical activity

• Taking prescribed medications (including aspirin)

• Performing foot care 

• Making routine visits to health care providers for 

foot, dental, and eye care

• Stopping smoking

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PRINCIPLE 7: 

Identify and Treat 

Long-term Diabetes Problems 

People with diabetes should have regular exams to help find and treat diabetes problems.

All diabetes problems have effective treatments. 

Routine checking for long-term complications can

help detect problems at a time when they can be

treated and managed successfully. The physical

examination and laboratory tests that identify 

early complications include:

At each diabetes visit:

• Blood pressure

• Weight check 

• Foot check

Annually:

• Lipid profile (every 2 years in normal)

• Dilated eye examination by a competent professional for detecting retinal and other eye complications (if normal, an eye care specialist may

advise an exam every 2 to 3 years)

• A physical examination for detecting nerve damage 

• Comprehensive foot exam to identify high risk

feet (by checking circulation, loss of feeling,

sores, or changes in shape) 

• Serum creatinine and urinalysis for protein,

microalbumin, albumin-to-creatinine ratio to

detect kidney disease

Twice each year:

• A1C (quarterly if patient is not meeting goals)

• Dental exams to prevent gum disease and 

loss of teeth

Vaccinations:

• Influenza (annually)

• Pneumoccal (usually only once, repeat if over 64

or immunocompromised and last vaccination was

more than 5 years ago)

Diabetes complications usually can be prevented 

or delayed if found and treated at an early stage.

Progression of cardiovascular disease leading to heart

attack and stroke can be slowed or prevented by 

rigorous management of blood pressure and lipids.

Diabetic kidney disease can be slowed or prevented

by controlling blood pressure and blood glucose.

Severe eye disease can be successfully treated by 

laser therapy. Circulatory complications in the legs,

heart, or brain may be improved by treatment,

including vascular surgery. These examples show 

the importance of treating long-term complications

at any stage of diabetes.

7 Principles for Controlling Your Diabetes for Life—A

booklet for people with diabetes that describes the

essential components of quality diabetes care in a

checklist form. 

4 Steps to Control Your Diabetes for Life—An 

easy-to-read booklet that condenses the guiding

principles and helps people with diabetes make

informed decisions about their diabetes care.

Be Smart About Your Heart: Control the ABCs of

Diabetes—A brochure that explains the ABCs of 

diabetes (A1C, Blood Pressure, and Cholesterol) and

provides a wallet card to help patients track 

their ABCs. Also available in Spanish and 15 Asian

and Pacific Islander languages.

If You Have Diabetes, Know Your Blood Sugar

Numbers—A pamphlet that explains the A1C test and

the importance of monitoring blood glucose control.

Control Your Diabetes. For Life. Tips to Help You Feel

Better and Stay Healthy—A handout that provides

tips for managing diabetes and a form to create a

personal diabetes action plan.

Tips for Helping a Person with Diabetes—A handout

that provides tips for helping a loved one with diabetes and includes a resource list.

Resources

The following NDEP publications contain information based on the Guiding Principles for Diabetes Care and are

designed for people with diabetes and their families. Free copies may be ordered by calling 1-800-438-5383 or they

may be downloaded from the NDEP’s website, www.ndep.nih.gov. As with all NDEP publications, these materials may

be reproduced and distributed without copyright restrictions.

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A joint program of the National Institutes of Health and

the Centers for Disease Control and Prevention

NIH Publication No. 99-4343 April 2004