Summary of Revisions for the 2003 Clinical Practice Recommendations:

• Diabetic Retinopathy "Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20-74 years..."
• Standards of Medical Care for Patients With Diabetes Mellitus "Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes..."
• Treatment of Hypertension in Adults With Diabetes "Hypertension (defined as a blood pressure 140/90 mmHg) is an extremely common comorbid condition in diabetes, affecting 20-60% of patients with diabetes, depending on obesity, ethnicity, and age. In type 2 diabetes, hypertension is often present as part of the metabolic syndrome..."
• Diabetic Nephropathy "Diabetes has become the most common single cause of end-stage renal disease (ESRD) in the U.S. and Europe..."
• Third Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies "Diabetes is a chronic disease that affects nearly 17 million Americans (1), with over 10 million cases diagnosed, and is characterized by serious, costly, and potentially fatal complications..."
• Translation of the Diabetes Nutrition Recommendations for Health Care Institutions "The "Nutrition Recommendations and Principles for People with Diabetes Mellitus"... provide diabetes medical nutrition therapy (MNT) guidelines for individuals living in a home setting; however, they do not include information about how to incorporate the recommendations into health care facilities..."
• Test of Glycemia in Diabetes "Monitoring of glycemic status, as performed by patients and health care providers, is considered a cornerstone of diabetes care. Results of monitoring are used to assess the efficacy of therapy and to guide adjustments in medical nutrition therapy (MNT), exercise, and medications to achieve the best possible blood glucose control..."
• Insulin Administration "Insulin is necessary for normal carbohydrate, protein, and fat metabolism. People with type 1 diabetes mellitus do not produce enough of this hormone to sustain life and therefore depend on exogenous insulin for survival. In contrast, individuals with type 2 diabetes are not dependent on exogenous insulin for survival. However, over time, many of these individuals will show decreased insulin production, therefore requiring supplemental insulin for adequate blood glucose control, especially during times of stress or illness..."

The ADA's Clinical Practice Recommendations for 2002 are available.

Additions to the Clinical Practice Recommendations:

• Treatment of Hypertension in Adult Patients With Diabetes Mellitus "Hypertension (defined as a blood pressure [greater or equal to] 140/90 mmHg) is an extremely common comorbid condition in diabetes..."
• Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Complications" position statement replaces the former position statement "Nutrition Recommendations and Principles for People with Diabetes Mellitus," "Food Labeling," and "Role of Fat Replacers in Diabetes Medical Nutrition Therapy "Medical nutrition therapy is an integral component of diabetes management and of diabetes self-management education. Yet many misconceptions exist concerning nutrition and diabetes. Moreover, in clinical practice, nutrition recommendations that have little or no supporting evidence have been and are still being given to persons with diabetes..."
• Standards of Medical Care for Patients With Diabetes was completely rewritten to incorporate ADA's evidence-based grading system. "Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed..."

• Hyperglycemic Crises "Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly..."
• Insulin Administration "Insulin is necessary for normal carbohydrate, protein, and fat metabolism..."
• Diabetic Nephropathy "Diabetes has become the most common single cause of end-stage renal disease (ESRD) in the U.S. and Europe.."
• Tests of Glycemia "Monitoring of glycemic status, as performed by patients and health care providers, is considered a cornerstone of diabetes care..."
• Care of Children with Diabetes in the School and Day Care Setting "Diabetes is one of the most common chronic diseases of childhood... Both parents and the health care team should work together to provide school systems and day care providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience..."
• Management of Diabetes at Diabetes Camps "Since Leonard F.C. Wendt, MD opened the doors of the first diabetes camp in Michigan in 1925, the concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world..."
• Prevention of Type 1 Diabetes Mellitus "...Because we now have the ability to predict the development of type 1 diabetes in some people, investigators have begun to explore the use of intervention therapy to halt or even prevent ß-cell destruction in such individuals..."

The following documents were in the ADA's 2001 Clinical Practice Recommendations

Additions to the Clinical Practice Recommendations for 2001:

• Hyperglycemic Crises in Patients with Diabetes Mellitus "Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. These disorders can occur in both type 1 and type 2 diabetes." S83

• Evidence gradings, using the American Diabetes Association's grading system, for all new or significantly revised position statements.

The following documents were in the ADA's 2000 Clinical Practice Recommendations

Additions to the Clinical Practice Recommendations for 2000:

• Smoking and Diabetes "...a large body of evidence from epidemiological, case-control, and cohort studies provides convincing documentation of the causal link between cigarette smoking and health risks. Cigarette smoking is the leading avoidable cause of mortality in the U.S., accounting for ~434,000 deaths each year. Cigarette smoking accounts for one out of every five deaths in the U.S. and is the most important modifiable cause of premature death..." S63
• Immunization and the Prevention of Influenza and Pneumococcal Disease in Patients with Diabetes "The rationale for the use of influenza and pneumococcal vaccine in patients with diabetes ... can be summarized as follows: * Patients with diabetes may have abnormalities in immune function and presumed increased morbidity and mortality from infection. * Epidemiological studies support the fact that patients with diabetes ...are at high risk ... * There is sufficient evidence that people with diabetes generally have appropriate humoral immune responses to vaccination. * There are few clinical trials of vaccine efficacy specifically in patients with diabetes. * Subgroup analysis of patients with diabetes reported in clinical narrative and case-control studies support the fact that vaccination against influenza has been effective in reducing hospital admissions during influenza epidemics. * Although the question of the efficacy of pneumococcal vaccination in preventing nonbacteremic disease remains unresolved, many studies have shown that the vaccine is effective in reducing life-threatening bacteremic disease. * Immunization against influenza and pneumococcal disease is an important part of preventive services for many chronic diseases such as diabetes..." S91
• Pancreas and Islet Transplantation for People with Type 1 Diabetes (Will replace an earlier position statement, Pancreas Transplantation for Patients With Diabetes Mellitus.) "Successful pancreas transplantation has been demonstrated to be efficacious in significantly improving the quality of life of people with diabetes, primarily by eliminating the need for exogenous insulin, frequent daily blood glucose measurements, and many of the dietary restrictions imposed by the disorder. Transplantation can also eliminate the acute complications commonly experienced by patients with type 1 diabetes (e.g., hypoglycemia and hyperglycemia). Pancreas transplantation is only partially successful in reversing the long-term renal and neural complications of diabetes..." S85

The following documents were in the ADA's 1999 Clinical Practice Recommendations

Additions to the Clinical Practice Recommendations for 1999:

• Implications of the United Kingdom Prospective Diabetes Study "We now have the results of the largest and longest study on type 2 diabetic patients that has ever been performed. The United Kingdom Prospective Diabetes Study (UKPDS) recruited 5,102 patients with newly diagnosed type 2 diabetes in 23 centers within the U.K. between 1977 and 1991..." S27
• Preventive Foot Care in People With Diabetes "Foot ulcers and amputations are a major cause of morbidity, disability, and costs for people with diabetes. The early recognition and management of risk factors for ulcers and amputations can prevent or delay the onset of these adverse outcomes. This position statement provides recommendations for people currently with no foot ulcers and outlines the best means to identify and manage risk factors before a foot ulcer occurs or an amputation becomes imminent. These recommendations are based on the technical review of care for the nonulcerated foot in diabetes. A later American Diabetes Association consensus statement will cover the management of the diabetic foot ulcer, surgical management, and diabetic arthropathy..." S54
• Care of Children With Diabetes in the School and Day Care Setting "Diabetes is one of the most common chronic diseases of childhood, with an incidence of ~1.7 affected individuals per 1000 people aged <20 years. In the U.S., ~13,000 new cases are diagnosed annually in children. Only asthma exceeds its prevalence in the school-aged population. There are about 125,000 individuals <19 years of age with diabetes in the U.S. The majority of these young people attend school and/or some type of day care and need knowledgeable staff to provide a safe school environment..." S94
• Management of Diabetes at Diabetes Camps "Since Leonard F.C. Wendt, MD opened the doors of the first diabetes camp in Michigan in 1925, the concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world. It is estimated that worldwide camps serve 15,000-20,000 campers with diabetes each summer..." S98

The following documents were in the ADA's 1998 Clinical Practice Recommendations

Additions to the Clinical Practice Recommendations for 1998:

• Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (S5) "The current classification and diagnosis of diabetes used in the U.S. was developed by the National Diabetes Data Group (NDDG) and published in 1979... It is now considered to be particularly important to move away from a system that appears to base the classification of the disease, in large part, on the type of pharmacological treatment used in its management toward a system based on disease etiology where possible."
• Management of Dyslipidemia in Adults With Diabetes (S36) "...The rationale for the treatment of diabetic dyslipidemia is discussed in detail in the American Diabetes Association (ADA) technical review... Type 2 diabetes is associated with a two- to fourfold excess risk of coronary heart disease (CHD)."
• Aspirin Therapy in Diabetes (S45) "People with diabetes have a two- to fourfold increase in the risk of dying from the complications of cardiovascular disease. Both men and women are at increased risk."
• List of Technical Reviews (S91) "A technical review is a balanced review and analysis of the literature on a scientific or medical topic related to diabetes. The technical review provides a scientific rationale for a position statement..."

The following document was in the ADA's 1997 Clinical Practice Recommendations

• Guide to Diagnosis and Classification of Diabetes Mellitus and Other Categories of Glucose Intolerance (S21) "Diabetes mellitus is a heterogeneous syndrome. Its primary manifestation, hyperglycemia, can arise from various causes. The outline below is intended to aid the practicing physician in diagnosing and classifying disease states characterized by elevated plasma glucose..."

The following document was in the ADA's 1996 Clinical Practice Recommendations

• Urine Glucose and Ketone Determinations (S35) "Historically, urine glucose and ketone determinations were the only practical way for people with diabetes to regularly assess their glycemic control. However, the development of small, convenient, and reasonably accurate blood glucose meters has made urine glucose testing obsolete for most patients. Self-monitoring of blood glucose (SMBG) is now common and is the preferred way to monitor glycemic control. SMBG is recommended for all patients who use insulin. Recommendations for testing urine for glucose and ketones as part of diabetes management are described here..."