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POSITION STATEMENT Standards of Medical Care for Patients With Mellitus

iabetes is a chronic illness that requires contin- Dietary habits, nutritional status, and weight history; uing medical care and education to prevent acute growth and development in children complications and to reduce the risk of long- Details of previous treatment programs, including Dterm complications. People with diabetes should diabetes education receive their treatment and care from physicians with Current treatment of diabetes, including medications, expertise and a special interest in diabetes. The follow- diet, and results of ing standards define basic (minimum) medical care for Exercise history people with diabetes. These standards are not intended Frequency, severity, and cause of acute complica- to preclude more extensive evaluation and management tions such as ketoacidosis and of the patient. For more detailed information refer to Prior or current infections, particularly skin, foot, den- Physician's Guide to -Dependent (Type I) Dia- tal, and genitourinary betes: Diagnosis and Treatment and Physician's Guide Symptoms and treatment of chronic complications to Non-Insulin-Dependent (Type II) Diabetes: Diagnosis associated with diabetes: eye, , kidney, nerve, and Treatment. sexual function, peripheral vascular, and cerebral vascular Other medications that may affect blood glucose INITIAL VISIT concentration Risk factors for atherosclerosis: smoking, hyperten- Medical history. The comprehensive medical history sion, obesity, hyperlipidemia, and family history can uncover symptoms that will help establish the di- Psychosocial and economic factors that might influ- agnosis in the patient with previously unrecognized di- ence the management of diabetes abetes. If the diagnosis of diabetes has already been Family and other endocrine dis- made, the history should confirm the diagnosis, review orders the previous treatment, help evaluate the present degree Gestational history: , delivery of an in- of glycemic control, determine the presence or absence fant weighing >9 Ib, toxemia, stillbirth, polyhydram- of the chronic complications of diabetes, assist in for- nios, or other complications of pregnancy mulating a management plan, and provide a basis for continuing care. Elements of the medical history of par- ticular concern in patients with diabetes include: Physical examination. A complete physical examina- tion should be performed during the initial evaluation. • Symptoms and laboratory test results related to the Individuals with diabetes are at high risk of developing diagnosis of diabetes eye, kidney, nerve, cardiac, and vascular complica- tions. Patients with type I (insulin-dependent) diabetes also have an increased frequency of thyroid disease, and Originally approved October 1988. Reprinted from Diabetes Care 12:365-68, 1989. all individuals with diabetes are at increased risk of in- Copyright 1989 by the American Diabetes Association. fections. Children may have delayed growth and mat-

10 DIABETES CARE, VOL. 14, SUPPL. 2, MARCH 1991 POSITION STATEMENT uration. Therefore, certain aspects of the physical ex- providing written material appropriate to the patient/ amination require special attention. These include: family educational level. The management plan should include: • Height and weight measurement (and comparison to norms in children) • Statement of goals • Sexual maturation staging • Medications: insulin, oral glucose-lowering agents, • Blood pressure determination (with orthostatic mea- antihypertensive, lipid-lowering agents, or other surements) medications as needed • Ophthalmoscopic examination, if possible with dila- • Individualized nutrition recommendations and in- tion structions, preferably by a dietitian • Thyroid palpation • Recommendations for life-style changes (e.g., exer- • Cardiac examination cise, smoking cessation) • Evaluation of pulses (with auscultation) • Patient and family education: assessment of knowl- • Foot examination edge and understanding of diabetes and diabetes • Skin examination (including insulin-injection sites) management skills; plan for education consistent with • Neurological examination the National Standards for Diabetes Patient Education • Dental and periodontal examination of the American Diabetes Association • Monitoring instructions: self-monitoring of blood and/ The examiner should also be alert for signs of diseases or urine glucose, urine ketones, and use of a record that can cause secondary diabetes, e.g., hemochroma- system tosis, pancreatic disease, and endocrine disorders such • Referral to an eye doctor for a comprehensive eye and as acromegaly and Cushing's syndrome. visual examination: all patients aged 12-30 yr with Laboratory evaluation. Each patient should undergo a diagnosis of diabetes of at least 5 yr duration or over laboratory tests that are appropriate to the evaluation of age 30 yr at time of diagnosis or any patient with the individual's general medical condition. In addi- visual symptoms and/or abnormalities tion, certain tests should be obtained to establish the • Consultation for specialized services as indicated diagnosis of diabetes, determine the degree of glycemic • Agreement on ongoing support and follow-up: return control, and define associated complications and risk appointment and when and how to contact the phy- factors. These include: sician or other members of the health-care team for • plasma glucose: a random plasma glucose may problem-solving and crisis management be obtained in an undiagnosed symptomatic patient • For women of childbearing age: discussion of contra- for diagnostic purposes ception and review of program of diabetes care before • Glycosylated hemoglobin (HbA! or HbAlc) and during pregnancy • Fasting : total , high-density li- poprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and CONTINUING CARE • Serum in adults or if proteinuria is present • Urinalysis: ketones, glucose, protein, microscopic if A continuing-care plan is an essential feature in the indicated; after 5 yr of diabetes or after puberty, total management plan of every patient with diabetes. At each urinary protein excretion should be measured by a visit, the patient's progress in achieving treatment goals microalbuminuria method if available should be evaluated, and problems that have occurred • Urine culture: if microscopic is abnormal or symp- should be reviewed. If goals are not being met, both the toms are present goals and the treatment plan need to be reassessed. • (T4 or thyroid-stimulating hor- mone) VISIT FREQUENCY • ECG (in adults) The frequency of patient visits depends on the type of Management plan. The management plan should be diabetes, degree of blood glucose control achieved, formulated as an individualized therapeutic alliance be- changes in the treatment regimen, and presence of com- tween the patient/family, the physician, and other mem- plications of diabetes or other medical conditions. bers of the health-care team (e.g., RN, RD) to achieve Patients starting insulin or having a major change in the desired level of diabetes control. Consideration must their insulin program may need to be in contact with be given to the age of the patient, school or work sched- their care provider as often as daily until glucose control ules and conditions, physical activity, eating habits, so- is achieved, the risk of hypoglycemia is low, and the cial situation and personality, and presence of compli- patient is competent to conduct the treatment program. cations of diabetes or other medical conditions. Some patients may require hospitalization for initiation Implementation of the management plan requires that or change of therapy. Contact with the patient after a each aspect be understood by the patient and the care major modification of the treatment plan should not be provider and that the goals and means be considered delayed >1 wk. realistic. Instructions and plans should be reinforced by Patients beginning treatment by diet or oral glucose-

DIABETES CARE, VOL. 14, SUPPL. 2, MARCH 1991 POSITION STATEMENT

lowering agents may need to be contacted weekly until tions should be measured and glomerular filtration as- reasonable glucose control is achieved and the patient sessed. is competent to conduct the treatment program. Contact Management plan. The plan should be reviewed at with these patients after a major modification of the each regular visit to determine progress in meeting goals treatment plan should be no more than 1 mo later. and to identify problems. This review should include Regular visits should be scheduled for insulin-treated nutritional evaluation and weight control, the exercise patients at least quarterly and for other patients at least regimen, the control of blood glucose and desired lipid semiannually. All patients must be taught some method levels, frequency of hypoglycemia, adherence to all as- of monitoring glycemic control. In insulin-treated pa- pects of self-care, assessment of complications, follow- tients, and in non-insulin-treated patients with poor up of referrals, and psychological adjustment. In addi- metabolic control, this should be blood glucose testing; tion, knowledge of diabetes and self-management skills in other patients, blood glucose testing may be useful. should be reassessed at least annually. Patients must be taught to recognize problems with their glucose control and to report problems to the health- care team. They also should be taught to recognize early INTERCURRENT ILLNESS signs and symptoms of acute and chronic complications and to report these promptly. The stress of illness frequently aggravates the hypergly- cemia of diabetes, and during such illness, blood glu- ELEMENTS OF CONTINUING CARE cose and urine ketones should be monitored frequently. Medical history. An interim history should assess 7) Marked hyperglycemia requires temporary adjustment frequency, causes, and severity of hypoglycemia or hy- of the treatment program, and the patient treated with perglycemia; 2) results of regular glucose monitoring; oral hypoglycemic agents or diet alone may temporarily 3) adjustments by the patient of the therapeutic regimen; require insulin. Infection or dehydration is more likely 4) problems with adherence; 5) symptoms suggesting to necessitate hospitalization in the person with diabetes development of the complications of diabetes; 6) psy- than in the person without diabetes. If possible, the hos- chosocial status; 7) other medical illnesses; and 8) cur- pitalized patient should be treated by a physician with rent medications. expertise in the management of diabetes. Physical exam. A comprehensive physical examination should be performed annually. A complete eye and vis- ual examination by an eye doctor should be performed SPECIAL CONSIDERATIONS at least annually in all patients >30 yr old and in pa- tients between 12 and 30 yr of age with a diagnosis of and hyperosmolar coma. These diabetes of at least 5 yr duration. conditions represent decompensation in diabetic control At every regular visit, the following should be mea- and require immediate treatment. Depending on the se- sured: height (until maturity), weight, sexual maturation verity of the illness and available resources, treatment in adolescents, and blood pressure. Portions of the phys- can be undertaken in the physician's office, emergency ical examination that were found to be abnormal on room, hospital room, or medical intensive-care unit. Re- previous visits should be repeated. The feet should be currence demands a detailed psychosocial and educa- examined routinely. The examination should also be tional evaluation by a diabetes specialist. extended to include areas indicated by the interim his- Severe or frequent hypoglycemia. The occurrence of tory. severe, frequent, or unexplained episodes of hypogly- Laboratory. A glycosylated hemoglobin determination cemia requires evaluation of both the management plan should be performed at least semiannually in all patients and its execution by the patient and may indicate a need and preferably quarterly in insulin-treated patients and to revise the plan or reeducate the patient. The accom- in non-insulin-treated patients with poor metabolic con- plishment of these goals generally requires more fre- trol. A fasting plasma glucose test may be useful to judge quent patient visits during adjustment of the treatment glycemic control in patients with type II (non-insulin- program. dependent) diabetes. The value obtained from a random Pregnancy. To reduce the risk of fetal malformations plasma glucose test may be useful for comparison with and maternal and fetal complications, pregnant women the value obtained simultaneously by the patient using and women planning pregnancy require excellent blood his/her own monitoring systems. glucose control. These women need to be seen by a Triglycerides, total cholesterol, and HDL cholesterol physician frequently, must be trained in self-monitoring should be tested annually in adults and every 2 yr in of blood glucose, and may require specialized labora- children. tory and diagnostic tests. Consultation with an obstetri- Routine urinalysis should be performed yearly. After cian and medical specialist in diabetes is indicated be- 5 yr duration of diabetes, or after puberty, total urinary fore pregnancy. protein excretion should be measured yearly, by a mi- . Hypertension contributes to the devel- croalbuminuria method if possible. If proteinuria is de- opment and progression of chronic complications of di- tected, serum creatinine or urea nitrogen concentra- abetes. Hypertension should be treated aggressively to

12 DIABETES CARE, VOL. 14, SUPPL. 2, MARCH 1991 POSITION STATEMENT achieve and maintain blood pressure in the normal range. educated about the risk and prevention of foot prob- The selection of an antihypertensive drug should be in- lems. dividualized to minimize the number and severity of Children and adolescents. Children and adolescents side effects. For example, (3-blockers should be used with diabetes, especially preschoolers and teenagers, with caution in insulin-treated individuals because these should be managed in consultation with a physician drugs may mask early symptoms of hypoglycemia and who has expertise in treating children with diabetes. prolong recovery from hypoglycemia. Retinopathy. or other visual ab- normalities require care by an ophthalmologist experi- REFERENCES enced in the management of people with diabetes. Nephropathy. The patient with abnormal renal func- 1. Physician's Cuide to Insulin-Dependent (Type I) Diabetes: tion (proteinuria or elevated serum creatinine) requires Diagnosis and Treatment. Alexandria, VA, Am. Diabetes heightened attention and control of other risk factors Assoc, 1988 (e.g., hypertension, smoking) and requires consultation 2. Physician's Guide to Non-lnsulin-Dependent (Type II) Di- with a specialist in diabetic renal disease. abetes: Diagnosis and Treatment. 2nd ed. Alexandria, VA, Cardiovascular disease. Patients with cardiovascular Am. Diabetes Assoc, 1988 risk factors should be carefully monitored. Evidence of 3. Goals for Diabetes Education. Alexandria, VA, Am. Di- cardiovascular disease such as angina, decreased pulses, abetes Assoc, 1987 4. Nutrition Guide for Professionals: Diabetes Education and and ECG abnormalities requires efforts aimed at correc- /v/ea/P/ann/ng. Alexandria, VA, Am. Diabetes Assoc, 1988 tion of contributing risk factors (e.g., obesity, smoking, 5. ADA position statement: Office guide to diagnosis and hypertension, sedentary life-style, hyperlipidemia, poorly classification of diabetes mellitus and other categories of regulated diabetes) in addition to specific treatment of glucose intolerance. Diabetes Care 4:335, 1981 the cardiovascular problem. 6. ADA position statement: mellitus. Neuropathy. may result in painful Diabetes Care 9:430-31, 1986 paresthesias, muscle weakness, and loss of sensation. 7. ADA position statement: Nutritional recommendations and Autonomic involvement can affect the function of var- principles for individuals with diabetes mellitus: 1986. ious organ systems (gastrointestinal, cardiovascular, Diabetes Care 10:126-32, 1987 8. ADA position statement: Eye care guidelines for patients genitourinary) and may require consultation with an ap- with diabetes mellitus. Diabetes Care 11:745-46, 1988 propriate medical specialist. 9. National standards for diabetes patient education and Foot care. Problems involving the feet may require care American Diabetes Association review criteria. Diabetes by a podiatrist or other medical professional experi- Care 9:XXXVI-XL, 1986 enced in the management of people with diabetes. Pa- 10. Consensus statement on self-monitoring of blood glucose. tients with evidence of sensory neuropathy should be Diabetes Care 10:95-99, 1987

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