U.S. Department of Health and Human Services

Introduction: About Guiding Principles for Diabetes Care

The large health and financial impact of diabetes and the existing gaps in achievement of treatment and prevention goals prompted the National Diab​etes Education Program (NDEP) to work with key partner organizations to develop these Guiding Principles. Several organizations have independently developed evidence-based guidelines for the care of people with diabetes. Attention is often focused on the relatively minor areas of disagreement among such guidelines. These Guiding Principles aim to identify and synthesize areas of general agreement among existing guidelines to help guide primary care providers and health care teams* to deliver quality care to adults with or at risk for diabetes. No evidence-based guidelines have been developed for this resource.

The 10 clinically useful principles presented here were developed by the NDEP and representatives from the American Academy of Family Physicians, the American Association of Clinical Endocrinologists, the American College of Physicians, the American Diabetes Association, the American Heart Association, Endocrine Society, and The American Geriatrics Society. These and other organizations and professional societies, as well as the numerous government organizations that are members of the Diabetes Mellitus Interagency Coordinating Committee, participated in an extensive and substantive review process.

* Throughout this document, the term “health care team” refers to the broad and multidisciplinary group of professionals who care for people with or at risk for diabetes, including (but not limited to) physicians, nurse practitioners, physician assistants, podiatrists, pharmacists, nurses, registered dietitians/registered dietitian nutritionists, diabetes educators, optometrists, ophthalmologists, psychiatrists, psychologists, case managers, social workers, dental professionals, community health workers, and other community partners.


The Diabetes Problem

Today, 29.1 million people (9.3 percent of the U.S. population) have diabetes, including 8.1 million who are undiagnosed.1 A major cause of blindness, renal failure, amputation, and cardiovascular disease, diabetes also increases the risk of cancer and dementia and more than doubles individual health care costs. The total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity.2

Twenty-one million U.S. adults have diagnosed diabetes, and of this population, about 90 to 95 percent have type 2 diabetes. Another 86 million Americans have prediabetes and are at high risk of developing type 2 diabetes.1

Proper nutrition and physical activity are the cornerstone of treatment and prevention of type 2 diabetes.3, 4 In addition to lifestyle modifications, controlling blood glucose, blood pressure, and cholesterol dramatically improves health outcomes.5, 6 As a result of improved risk factor control, rates of complications, particularly for cardiovascular disease, have declined.7

Yet diabetes management is suboptimal, particularly in disproportionately affected poor and/or minority populations.8 Analysis of national survey data from 1999 to 2010 for adults with diabetes found improvement in glycemic control, blood pressure, and blood lipids. However, for each measure, 33 to 49 percent of people with diabetes still did not meet target values, and one in five people with diabetes (20 percent) uses some form of tobacco. Only 14 percent met the targets for all three measures and did not use tobacco products.9

The National Institutes of Health—sponsored Diabetes Prevention Program clinical trial proved that type 2 diabetes can be delayed or prevented in high-risk individuals with prediabetes through lifestyle changes, such as improved nutrition and physical activity that result in modest weight loss, or the drug metformin.10 An estimated 93 percent of Americans with prediabetes are unaware of the condition.11 People at high risk for type 2 diabetes must be identified and targeted for ongoing diabetes primary prevention efforts if society is to realize the benefits of therapies proven to delay or prevent the disease. Otherwise, diabetes prevalence will continue to rise; one study projected the lifetime risk of diabetes diagnosis for Americans adults is 40 percent, meaning 2 out of every 5 American adults may be diagnosed if current trends continue.12


Focus on Type 2 Diabetes

Because type 2 diabetes comprises such a large proportion of people with or at risk of diabetes, these Guiding Principles focus primarily on prevention and management of type 2 diabetes in adults. While much of the material is also relevant to type 1 diabetes, gestational diabetes, type 2 diabetes in children, and other rarer forms of the disease, specific management of these forms is outside the scope of this document. The principles highlight the generally agreed-upon elements of current evidence-based diabetes management and prevention. References are limited to major research findings. References and key resources are provided at the end of each section.


Acknowledgments

Many National Diabetes Education Program (NDEP) partners contributed to the development of the Guiding Principles for the Care of People With or at Risk for Diabetes. A core writing and review team, the Guiding Principles Task Group, helped research, write, and refine content drafts. Their dedication and assistance were invaluable.

Members of the NDEP Executive Committee also participated in research, writing, and review of content.

  • John Buse, MD, PhD, NDEP Chair
  • Ann Albright, PhD, RD
  • Judith Fradkin, MD
  • Martha Funnell, MS, RN, CDE

NDEP Staff

  • Joanne Gallivan, MS, RD, Director, NDEP, NIH
  • Judith McDivitt, PhD, Director, NDEP, CDC
  • Diane Tuncer, Deputy Director, NDEP, NIH
  • Elizabeth Warren-Boulton, RN, MSN, Hager Sharp, Inc.
  • Catherine Brown, MS, RD, CDE, Hager Sharp, Inc.

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.

2. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46.

3. Academy of Nutrition and Dietetics Evidence Analysis Library. How effective is MNT provided by registered dietitians in the management of type 1 and type 2 diabetes? http://andevidencelibrary.com/evidence.cfm?evidence_summary_id=250466. Accessed on September 10, 2013.

4. Rejeski WJ, Ip EH, Bertoni AG, et al. Lifestyle change and mobility in obese adults with type 2 diabetes. N Engl J Med. 2012;366(13):1209–17.

5. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14–80.

6. 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.

7. Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990–2010. N Engl J Med. 2014;370(16):1514–23.

8. Stark Casagrande S, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care.2013;36(8):2271–9.

9. Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999–2010. N Engl J Med. 2013;368(17):1613–24.

10. 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.

11. Geiss LS, James C, Gregg EW, Albright A, Williamson DF, Cowie CC. Diabetes risk reduction behaviors among U.S. adults with prediabetes. Am J Prev Med. 2010;38(4):403–9.

12. Gregg EW, Zhou X, Cheng YJ, Albright AL, Narayan KV, Thompson TJ. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985–2011: a modelling study. The Lancet Diabetes & Endocrinology. 2014. doi:10.1016/S2213-8587(14)70161-5.

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