Standards of Medical Care in Diabetes—2006

American Diabetes Association. Diabetes Care. 2006;29(suppl1):S4-S42.

The American Diabetes Association (ADA) updates its position statements on an annual basis. For 2006, a number of important additions and revisions were made to the Standards of Medical Care.

In terms of additions, an extensively enhanced medical nutrition therapy (MNT) component was added. Recommendations in this area include the need for all patients with diabetes to receive MNT (preferably by a registered dietitian), the importance of type and amount of carbohydrate to glycemic control, and the potential added benefit that use of the glycemic index can provide over consideration of carbohydrate amount alone. Specific recommendations for various dietary components (eg, carbohydrate, protein, fat, fiber, reduced caloric sweeteners, alcohol, chromium, and alcohol) are also provided.

In 2006, diabetes self-management education (DSME) was also added to the Standards of Medical Care. According to ADA recommendations, DSME should be provided to all patients with diabetes at the time of their diagnosis and as needed thereafter. Furthermore, the ADA recommends that DSME should be provided by healthcare providers with appropriate training and continuing education. In terms of content, DSME should address psychosocial issues, especially as they pertain to diabetes self-care. Finally, the ADA recommends that DSME be reimbursed by third-party payors.

Guidelines for physical activity are also included this year for the first time. Because physical activity has been shown to reduce cardiovascular disease risk and enhance weight maintenance, current guidelines recommend at least 150 minutes of moderately intense aerobic activity and/or at least 90 minutes or vigorous aerobic activity per week. Furthermore, patients with type 2 diabetes who do not have contraindications should perform resistance training on all muscle groups. Advice for physical activity in the presence of a variety of different diabetic complications is also provided.

A new addition to information on diabetic complications for 2006 is the information on neuropathy (previous guidelines only addressed foot care). According to ADA recommendations, all patients should be screened for distal symmetric polyneuropathy at the time of diagnosis and annually thereafter. Screening can be done using simple clinical tests such as a tuning fork or monofilament; electrophysiological testing is rarely needed. Insensate feet should be examined every 3 to 6 months. Screening for autonomic neuropathy should be done at time of diagnosis with type 2 diabetes or 5 years after diagnosis of type 1 diabetes. Patients should be educated regarding proper foot care and should be referred for special footwear or inserts when needed. Additionally, there are a number of treatment options available to help patients manage symptoms of painful diabetic neuropathy.

The guidelines for 2006 also include some changes from last year. First, point-of-care testing for glycemic control is recommended so that timely therapy decisions can be made. Although the goal for patients, in general, is A1C<7%, the goal for individual patients is as close to normal as possible (6%) without significant risk of hypoglycemia. New recommendations for the reduction of nephropathy risk include limitation of protein intake to the Recommended Daily Allowance of 0.8 g/kg for patients with any degree of chronic kidney disease. To screen for nephropathy, serum creatinine should be measured at least annually so that glomerular filtration rate (GFR) can be calculated in all adults with diabetes, regardless of level of albuminuria. Serum creatinine alone should not be used as a measure of kidney function, but should be used to assess GFR and to stage the level of kidney disease.