These guidelines are endorsed under the authority of the
Florida Health Care and Insurance Reform Act of 1993,
Section 408.02, Chapter 93-129, Laws of Florida.

Minimum Standards of Care
for Children with Diabetes

Approximately three-fourths of all newly diagnosed cases of Type 1 diabetes occur in children
(under 21 years of age). Children’s health care needs are different from adults in several ways. Providing health care to children must not only involve caring for their physical needs, but it must also be appropriate to their changing developmental stages.

It is important to remember that young children have a limited ability to communicate their needs or to indicate if they are in pain, and therefore, should not be expected to understand specific clinical interactions.

Assessment of Need for Hospitalization for Stabilization
of Newly Diagnosed Children with Diabetes

The child should be evaluated by a physician who has expertise in the diagnosis and treatment of children having diabetes and one who has knowledge of the growth and developmental stages for children.

Indications for Hospitalization for Diabetic Ketoacidosis (DKA)

One or more clinical and/or laboratory findings of DKA which may include the following:

* persistent vomiting,

* dehydration,

* lethargy,

* HCO3 <16 meq/1, or

* pH<7.25.

Other indications for hospitalization (one or more of the following):

* young age (<5 years),

* marked weight loss,

* no access to outpatient diabetes self-management training for greater than 24 hours,

* psycho-social issues - unstable family situation, affecting family’s ability to learn management of the illness, or

* geographic barriers - family’s home residence is not in close proximity to an outpatient diabetes program.

After Medical Stabilization (One to Three Days)

Diabetes self-management skills training must be provided by a team with expertise in providing care to children (must have knowledge and experience in the medical, psycho-social and developmental needs of children). Team members usually include at a minimum: physicians, a certified diabetes educator, a registered nurse, a licensed registered dietitian, psychologist, a social worker and school health nurse.

If the listed professionals are not used, the functional equivalent for each professional member not used must be documented.

Ongoing Disease Management - First Year

Frequent telephone contacts (minimum of one per month) for evaluation of glucose levels and insulin dosages. Immediately after diagnosis, telephone contact will be more frequent, as often as daily until blood glucose levels stabilize. The first month after diagnosis there should be at least weekly telephone calls until the established agreed upon target goals are achieved.

Office Visits

Office visits every three months, which should include:

* blood pressure measurements,

* growth assessment,

* nutrition assessment and adjustment,

* hemoglobin A1c level,

* assessment of self-management skills, and

* anticipatory guidance to developmental issues of child with diabetes.

Annual Assessment

An annual assessment should be completed which includes:

* Urinary albumin measurement or urinary albumin/creatinine ratio – in pubertal and postpubertal Type l patients who have had diabetes for at least five years, or from puberty on,

* Ophthalmology referral for a comprehensive dilated eye exam by an eye care specialist (optometrist or ophthalmologist) with expertise in the care of diabetes for patients > 10 years of age starting 3 to 5 years after the onset in patients with no visual symptoms, and then annually thereafter. Patients with visual symptoms should be evaluated at the time the symptoms develop, and then re-evaluated at least annually . More frequent exams are indicated, if problems develop,

* Dental examination,

* Thyroid antibodies should be obtained at diagnosis if goiter or thyroid symptoms are present thyroid function and thyroid antibodies should also be measured, and

* Attendance at a diabetes camp is considered a valuable adjunct to management of this disease and participation is encouraged.

Second Year and Beyond

Patients should have a monthly glucose review, which may be completed by telephone or fax.

Office visits every three to four months, which should include:

* blood pressure measurements,

* growth assessment,

* hemoglobin A1c level,

* assessment of self-management skills,

* assessment of family adjustment to diabetes, including patients, parents, siblings, friends,
and teachers,

* anticipatory guidance to developmental issues of child with diabetes, and

* nutritional assessment and adjustment (minimum of two times annually).

Patients with hemoglobin A1c levels >11 percent (normal range 3 to 6 percent) or multiple episodes of DKA requiring an emergency room visit or hospitalization should have follow-up monthly office visits until improvement is sustained (individual needs may vary) which should include an:

* evaluation by a physician with expertise in diabetes and in the growth and developmental stages of children, and

* assessment of self-management skills by multi-disciplinary team, which should include a psychologist or social worker to provide education and counseling for the improvement of self-management skills, and working with the child’s day care or preschool teacher and the school health nurse on care plans for the child while in school.

Criteria that Suggest Children or Adolescents have
Type 2 Diabetes

Testing for Type 2 diabetes is recommended when the following three criteria are met:

* children 10 years of age or older, or at the onset of puberty if this occurs before age 10 (testing should be done every two years),

* overweight (BMI >85^th percentile for age and sex, weight for height > 85^th percentile, or weight > 120 percent of ideal weight for height), and

At least two of the risk factors listed below must be present:

– family history of Type 2 diabetes in first or second degree relatives,

– membership in any of these ethnic groups: American Indian, African American, Hispanic, or Asian/Pacific Islander

– signs of insulin resistance or conditions associated with insulin resistance:

ú acanthosis nigricans,

ú high blood pressure,

ú dyslipidemia, or

ú polycystic ovarian syndrome (PCOS).

Treatment Goals for Children with Type 2 Diabetes

Goals for children with Type 2 diabetes are:

* normal fasting blood glucose values (FPG < 126 mg/dl),

* near normal hemoglobin A1c levels (<7 percent in most laboratories),

* cesation of excessive weight gain with normal linear growth, and

* control of associated comorbidities such as high blood pressure or high blood lipids.

Treatment Components for Type 2 Diabetes

Education

Children should receive comprehensive self-management education. It is critical that health care providers work with both the child and parents and/or guardians in establishing treatment goals, to resolve problems that occur and modify goals as appropriate.

Monitoring

Physicians should:

* recommend self monitoring of blood glucose as needed, and during periods of acute illness or when symptoms of hyper- or hypoglycemia occur,

* ask patients on insulin or oral agents to self monitor for asymptomatic hypoglycemia,

* tailor routine self monitoring of blood glucose to the child’s needs, which should probably include fasting and postprandial glucose measurements, and

* assess hemoglobin A1c levels at least quarterly.

Nutrition Therapy

Children diagnosed with Type 2 diabetes should:

* be referred to a dietitian knowledgeable and experienced in the nutrition management of diabetes in children,

* be given encouragement and assistance for achieving healthy eating habits by the entire family, especially for decreasing high-caloric, high-fat food choices; health care team members should encourage weight reduction in children with BMI > 85^th percentile.

Exercise

Physicians and other members of the health care team should:

* encourage increased daily physical activity and discourage sedentary activities (e.g., watching television and using the computer), and

* involve family members who will provide positive reinforcement for increased physical activities.

Follow-up Visits

Physicians should:

* provide periodic re-evaluation and reinforcement of treatment (every 3 to 4 months), and

* recommend increased self-monitoring of blood glucose (SMBG) and contact with the health are team, child day care provider, and school nurse when treatment goals are not met.

Drug Therapy

Remember that for type 2 diabetes a number of regimens may be applied such as:

Initial Insulin Treatment

(for children with high blood glucose or significant symptoms)

* starting insulin therapy with bedtime dose alone, twice a day dosing, or multi-dose regimens. When glucose control is established, one option may also be to add metformin while decreasing the insulin, and

* consider monitoring for urine ketones to identify children who may have Type I diabetes.

Initial Oral Medication

* prescribe metformin using the doses recommended for adults as the first oral agent when treatment goals are not met by nutrition and exercise interventions (Type 2 diabetes is a progressive disease and it is expected that most patients will require medication at some time including insulin),

* do not use metformin with children who have impaired renal function, known hepatic disease, hypoxemic conditions, severe infections, or alcohol abuse. Discontinue use with any acute illness associated with dehydration or hypoxemia. Insulin should be used if glycemic control sharply deteriorates, and

* provide preconception and pregnancy counseling to all females of childbearing age; metformin can normalize ovulatory abnormalities and increase the risk of unplanned pregnancy, especially in polycystic ovarian syndrome (PCOS). No oral agents should be used during pregnancy.

Additional Medication

Use one of several alternatives if the use of metformin more than 3 to 6 months is not successful in meeting the goals of therapy: (metformin is the only medication approved for children having Type 2 diabetes)

* add sulfonylurea,

* add insulin, especially for children with greatly elevated blood glucose levels or significant symptoms,

* add other insulin secretagogue (e.g., meglitinide) or glucosidase inhibitor, although these are less frequently used in children, or

* consider thiazolidinedione.

Monitoring for Complications

Ongoing medical evaluations should include:

* referral for a comprehensive dilated eye exam by an eye care specialist (optometrist or ophthalmologist) with expertise in the care of diabetes starting 5 years after the onset in patients with no visual symptoms, and then annually thereafter. Patients with visual symptoms should be evaluated at the time the symptoms develop, and then at least once a year. More frequent exams are indicated if problems develop,

* testing for microalbuminuria annually, and

* testing for high blood pressure and lipid abnormalities.

Treatment of Complications

Hypertension

* weight loss, exercise, and reduction of dietary sodium, to reduce high blood pressure, unless hypertension is at an urgent level; if pressure is not reduced to the age-adjusted 90^th percentile values, add medications in a stepwise fashion until blood pressure goal is achieved,

* treat high blood pressure with angiotensin converting enzyme inhibitors (ACEI), beta blockers, calcium channel antagonists (long-acting), and low dose diuretics,

* use of ACEI is the agent of choice for children with microalbuminuria, and many diabetologists consider ACEI the first line therapy for high blood pressure, and

* add other medications if normotension is not achieved.

Hyperlipidemia

* try weight loss, increased physical activity, improvement in glycemic control, and changes in food choices and their preparation to improve lipids levels. If these actions do not reduce low-density lipoprotein cholesterol to <110 mg/dl or triglycerides to less than 100mg/dl in children with risk factors in addition to diabetes, medications should be used.

* HMGCOA reductase inhibitors are absolutely contraindicated in pregnancy.

Diabetes Outpatient Care for Adults

Initial Assessment

Assess Patient’s Disease Status and Risk Factors

Complete patient history should include:

* prior or current infections,

* medications,

* family (including cultural factors),

* gestational history,

* weight/nutrition,

* exercise habits,

* immunization status for influenza and pneumococcus,

* medical (including chief complaint, duration of known disease),

* for women of childbearing age, discussion of menstrual cycle and contraception, and

* symptoms of complications/risk factors (i.e., atherosclerosis, hyperlipidemia, alcohol, and tobacco use).

Complete physical examination performed by physician which at a minimum must include:

* height/weight (BMI is encouraged),

* blood pressure (including orthostatic),

* dilated ophthalmoscopic exam by an eye care specialist (optometrist or ophthalmologist),

* thyroid palpation,

* cardiac,

* pulses,

* hand/fingers,

* feet,

* skin,

* abdominal,

* neurologic, and

* dental exam.

Complete laboratory tests evaluated by a physician which, at a minimum, must include:

* fasting or random plasma glucose,

* hemoglobin A1c,

* fasting lipid profile,

* serum electrolytes,

* serum creatinine,

* urinalysis,

* TSH,

* timed urinary albumin:creatinine ratio if urine analysis negative for protein, and

* ECG.

A complete evaluation of the patient’s support system must be completed by the physician or other diabetes health team members. The evaluation should include the following:

* family and/or significant friends or relationships,

* identification of other support systems (e.g., house of worship, school, civic organizations, and clubs),

* work history and current work schedule and environment, and

* financial concerns (including insurance coverage).

Testing of the patient may be helpful to the physician and to the individual in determining the patient’s knowledge base and level of education. The clinician may want to complete:

* Diabetes Assessment and Teaching Record,

* AACE Knowledge Evaluation Forms,

* Michigan Diabetes Research and Training Center Diabetes Care Profile, or

* Beck Depression Inventory.

The patient will need to be assessed by other health care professionals during the initial assessment phase. Professional team members that should be involved in self-management training include:

* Certified diabetes educator – all patients,

* Licensed, registered dietitian – all patients,

* Physician/podiatrist –if necessary,

* Exercise physiologist – if necessary,

* Licensed mental health professional – if necessary, and

* Social worker – if necessary.

If a certified diabetes educator and licensed, registered dietitian is not used, a written explanation must be written in the patient’s chart.

It is critical that the patient understands the necessity of and agrees to an intensive treatment regime that will include diabetes self-management education. It is important to assess the patient’s knowledge base about diabetes and their motivation to learn about the treatment of the disease. The physician should discuss the following information with all newly diagnosed patients:

* pathophysiology of diabetes,

* rationale for intensive treatment,

* the role patient has in diabetes self-management, and

* goals of treatment.

Further discussion will also involve other members of the health care team.

The patient should receive initial instruction from the physician regarding:

* blood glucose self-monitoring,

* medication (including dosage adjustment and algorithms),

* complications,

* special situations,

* nutrition,

* preventive care,

* exercise*, and

* psychological aspects of the disease.

* Prior to initiating an exercise program, patients should have a detailed medical evaluation with appropriate diagnostic studies. Patients should be carefully screened for the presence of macro- and microvascular complications that may be worsened by the exercise program. This exam should focus on the symptoms and signs of disease affecting the heart and blood vessels, eyes, kidneys, and nervous system. A graded exercise test is recommended if a patient is about to begin a moderate- or high-intensity exercise program, and/or is at high risk for underlying cardiovascular disease.

A written plan for follow-up care, including office visits and education, should be reviewed and agreed upon by the patient, physician, and other health care team members.

During the initial phase, diabetes self-management education is critical to the treatment and management of this disease. Self-management training should be introduced within the first week of diagnosis.

* A minimum of 10 to 12 hours of instruction should be provided to all patients within 12 weeks of initial diagnosis.

* Self-management training is an ongoing process. Patients will require training beyond the initial self-management education and training as individual situations, lifestyle changes, and medical conditions mandate.

A detailed explanation of the core elements of a comprehensive diabetes self-management educational program is discussed later in this guideline.

Follow-up Assessments (Three-Month Intervals)

The physician should evaluate blood glucose control and disease complications. At a minimum, the physician should complete a patient history that addresses:

* acute problems,

* chronic problems,

* hypoglycemia,

* new symptoms suggestive of complications,

* interim illnesses,

* immunization status,

* medications,

* review of blood glucose self-monitoring, and

* changes in risk factors.

At a minimum, the following laboratory tests should be completed:

* random plasma glucose,

* hemoglobin A1c levels, and

* lipids if necessary.

The physical examination should be performed by a physician and at a minimum must include:

* weight (BMI is encouraged),

* blood pressure (including orthostatic, if indicated) ,

* eye exam, dilated if necessary,

* cardiac,

* pulses,

* feet,

* skin, and

* neurologic examination.

Based on clinical findings and evaluation of the patient, revisions may be made to the treatment plan that may involve changes in:

* medication (including dosage adjustment to algorithms),

* blood glucose self-monitoring,

* nutrition,

* exercise, and

* follow-up communications (via office visits and telephone contacts) between the patient and the health care professional team.

At the six month visit the physician should re-evaluate the patient’s understanding of diabetes and the necessity for diabetes self-management care. This may be completed through:

* objective tests of patient knowledge (standardized tests exist),

* psychological tests (standardized tests exist), and

* a review and update of the patient’s support systems.

Based on evaluation results, the patient may need additional education and referral to:

* certified diabetes educator,

* registered dietitian,

* exercise physiologist,

* licensed mental health professional, and/or

* social worker.

If a certified diabetes educator or licensed registered dietitian is not used, a written explanation must be written in the patient’s chart.

Prevention/Assessment of Complications

Glucose Control

The goal for hemoglobin A1c levels should be the same as currently adopted by the American Diabetes Association within one percent of normal or 7% for most laboratories. If this goal is not achieved this test should be completed at least quarterly. If the patient is not reaching the target goal, then the patient should be referred to an endocrinologist.

Retinal Evaluation

Newly diagnosed adults should be referred for an ophthalmologic exam by an eye care specialist (ophthalmologist or optometrist) with expertise in the care of diabetes as soon as practical after diagnosis. Patients should be educated regarding retinal complications. A re-evaluation by an ophthalmologist or optometrist should be completed annually.

Follow-up assessment should include:

* dilated eye exam,

* visual acuity test,

* funduscopic exam and photos (if indicated), and

* intra-ocular pressure (IOP).

Patients may require a referral to an ophthalmologist for further studies or for treatment based on findings of the most current exam.

Cardiac Peripheral Vascular Evaluation

This evaluationshould be completed annually.

Follow-up assessment should include:

* pulses, orthostatic blood pressure (erect and supine), and cardiac risk assessment,

* ECG based on age and symptoms, and

* lipid profile (cholesterol, triglycerides, HDL, LDL).

Patients should be educated regarding vascular complications. The documented increased risk for cardiovascular disease in people with diabetes mandates vigilance regarding triglyceride and LDL cholesterol levels.

The American Diabetes Association recommends a goal for total cholesterol of less than 200 mg/dl, LDL cholesterol of less than 100 mg/dl, and fasting triglycerides of less than 200 mg/dl. HDL cholesterol >45 mg/dl in men and >55 mg/dl in women.

Hypertension contributes to the development of cardiovascular, renal and retinal disease. Target values for individuals with diabetes are be lower than those for the general population. Blood pressure should be less than 130/80.

The frequency of follow-up care will be based on presence or absence of complications, or the development of symptoms and cardiac risk factors (family history, smoking, obesity sedentary lifestyle).

Additional evaluations may be required (e.g., stress test) or a referral to a cardiologist may be indicated based on findings of the most current exam. Re-evaluate patient’s exercise plan.

Aspirin Therapy

Aspirin therapy should be strongly considered as a prevention strategy in men and women who have evidence of large vessel disease. This includes those individuals having:

* history of myocardial infarction,

* vascular bypass procedure,

* stroke or transient ischemic attack,

* peripheral vascular disease,

* claudication, and/or

* angina.

In addition, aspirin therapy should be strongly considered for high risk women and men with Type 1 or Type 2 diabetes with any of the following:

* family history of coronary heart disease,

* cigarette smoking,

* hypertension,

* obesity,

* albuminuria (micro or macro),

* lipids

- cholesterol>200 mg/dl

- LDL cholesterol >100 mg/dl

- HDL cholesterol <45mg/dl in men and <55 mg/dl in women

- triglycerides > 200 mg/dl, and/or

* Age >30.

Tobacco Cessation

All patients with diabetes who are tobacco users should be counseled on tobacco cessation. Physicians may want to consider referral to cessation program.

Renal Evaluation

This evaluation should be completed annually.

Follow-up assessment should include the following lab tests:

* urinary albumin measurement or albumin:creatinine ratio, if urine protein is negative,

* 24-hour urine protein, if two screenings for microalbuminuria are positive,

* creatinine clearance, if necessary,

* creatinine and electrolytes, and

* Basic Metabolic Panel (BMP).

Patients should be educated regarding renal complications. The frequency of follow-up care will be based on the presence or absence of complications or the development of symptoms. Additional lab tests or x-ray studies as necessary should be completed. Patients with confirmed micro/macro albuminuria should be treated with an ACE inhibitor unless medically contraindicated.

Patients may require a referral to a registered licensed dietitian for instructions on modifications of protein intake.

Neuropathy Evaluation

This evaluation should be completed annually.

Follow-up assessment should include:

* a thorough foot examination by a physician/podiatrist,

* review of symptoms relevant to peripheral nerve and autonomic dysfunction,

* vibratory sensation, soft touch and pinprick testing should be completed, and

* consideration should be given to using a standardized measurement of neurological function such as the Semmes Weinstein Filaments.

Patients should be educated regarding neuropathic complications. The frequency of follow-up care will be based on the presence or absence of complications or the development of symptoms. Patients may require a referral to a neurologist which should be based on findings from the most current exam.

Immunization Evaluation

Patients with diabetes are at risk for adverse consequences from lower respiratory tract infections and should receive an annual influenza vaccination with the most currently formulated vaccine. This vaccine should be recommended for patients with diabetes, age> 6 months, beginning each September.

Patients with diabetes are also predisposed to an increased risk of pneumococcal illness and its complications. Individuals with diabetes should receive pneumococcal polysaccharide vaccine. Beginning after two years of age, the new pediatric pneumococcal vaccine should be given to children.

Prior to administering these vaccines, physicians should consult the current immunization schedules and recommendations endorsed by the Advisory Committee on Immunization Practices (ACIP).

Preconception Counseling

Prepregnancy counseling is critical for all women of childbearing potential. The physician is responsible for providing/referring for prepregnancy counseling. The counseling session must include information on the risk of congenital malformations to the child and ways to prevent them.

For women diagnosed with diabetes, and who are contemplating pregnancy and prior to conception, a complete history and physical assessment is imperative. The initial evaluation with the physician will probably last an hour, with subsequent visits lasting 20 minutes and occurring monthly during the average four months of preconception planning.

A complete history and evaluation should include, but is not limited to:

* discuss menstrual/pregnancy history, contraceptive use,

* establish data base for perinatal risk,

* acute and chronic complications,

* vascular status,

* glycemic control via hemoglobin A1c levels,

* optimize glycemic control, if Type 2 diabetic on oral agent, switch to insulin,

* if necessary, provide instruction regarding self-monitoring of blood glucose (SMBG),

* a nutritional assessment completed which includes an evaluation for nutritional adequacy, mke adjustments as needed,

* assess exercise program,

* determine immune status against rubella,

* assessment of support system and any psycho-social factors,

* determine if patient smokes, has excessive alcohol use, or substance use and if yes,

* explain possible dangers to both her and to the unborn child, and

* folic acid supplement.

A physical examination should be completed and include:

* blood pressure measurement, including orthostatic changes,

* dilated retinal examination by an ophthalmologist or optometrist experienced in the management of diabetic retinopathy. Patients may require a referral to an ophthalmologist for further screening or for treatment based on findings of current exam, and for a follow-up exam at the end of the first trimester of pregnancy,

* cardiovascular examination,

* neurologic assessment,

* lower extremity examination, and

* pelvic examination including pap smear.

Laboratory evaluations should include:

* hemoglobin A1c levels,

* assessment of renal function – serum creatinine and urinary excretion of total protein and/or albumin,

* thyroid function tests,

* lipid profile for Type 2 diabetics and obese women,

* ECG for those women diagnosed with diabetes for 10 years or more or who have other coronary artery disease risk factors, and

* other tests as indicated by the physical exam or history.

Discussions should be held with the patient and her partner concerning:

* management goals during pregnancy - normal glycemia,

* the role of self-monitoring of blood glucose (SMBG) and hemoglobin A1c levels,

* possible maternal and fetal risk complications, and

* cost implications of prenatal care and prevention of complications.

Follow-up visits with other health team members are critical.

The frequency of follow-up visits and the composition of team members to be seen will be dependent on the individual needs of the patient. Follow-up visits will usually last between 15 to 45 minutes, again depending on the problems identified.

Self-management techniques should be reviewed and modified as necessary. These sessions are used primarily for patient education, motivation, and instruction in more effective management strategies and techniques.

Women who have diabetes often have questions regarding the health effects on herself and possible consequences to her fetus. Physicians and other members of the health care team should be prepared to answer the following questions:

* Will the pregnancy affect my life expectancy?

* What effect will my diabetes have on the baby and will my child develop diabetes?

* What effect will the pregnancy have on diabetic nephropathy, retinopathy? and

* Are birth control pills safe for me to use?

As soon as possible (within two weeks) after a confirmation of pregnancy, a woman should be seen by the health care team. Emphasis needs to be placed on proper meal planning, to include:

* increased calcium,

* folic acid and iron,

* other vitamin intake,

* modifications to meals to address nausea and vomiting,

* gestational weight gain goals,

* risk assessment and prevention of fasting hypoglycemia,

* insulin adjustment algorithms to achieve target glucose control,

* quality control in SMBG, and

* any psycho-social concerns.

Gestational Diabetes

The onset of gestational diabetes occurs in women who manifest glucose intolerance during pregnancy. Since pregnancy stresses glucose metabolism, diabetes may manifest during this time.

Detection and Diagnosis

All pregnant women should be screened for glucose intolerance. Risk assessment for gestational diabetes should be undertaken at the first prenatal visit. Selective screening based on clinical factors or prior obstetrical history is inadequate.

Low Risk Characteristics

Women considered at minimal risk of having gestational diabetes requires no glucose testing. This category only applies to those women who meet all of the following characteristics:

* age < 25 years,

* weight normal before pregnancy,

* member of an ethnic group (generally white-non Hispanic) with a low prevalence of gestational diabetes,

* no known diabetes in first degree relatives,

* no history of abnormal glucose tolerance, and

* no history of poor obstetric outcome.

Women of average risk should have testing done at 24-28 weeks of gestation.

High Risk Characteristics

Women with clinical characteristics consistent with a high risk of gestational diabetes that include the following should have glucose testing as soon as feasible. If the initial screening is negative, they should be re-tested between 24-28 weeks of gestation.

* marked obesity,

* personal history of gestational diabetes,

* glycosuria, or

* a strong family history of diabetes.

Diagnosis of gestational diabetes is determined:

* by evaluating the results of the 100-g oral glucose tolerance during pregnancy that is interpreted according to the diagnostic criteria of O’Sullivan and Mahan Diagnostic Criteria:

* if two or more of the venous plasma glucose values are met or exceeded:

– fasting: 95 mg/dl

– 1 hour: 180 mg/dl

– 2 hours: 155 mg/dl

– 3 hours: 140 mg/dl

If either the fasting plasma glucose or random blood glucose meets or exceeds criteria for diagnosis, an oral glucose tolerance test (OGTT) is not needed.

Therapeutic Strategies

Maternal Strategies

Close monitoring of the mother and fetus must be maintained for all women who are diagnosed as having gestational diabetes.

For the mother, close monitoring is needed to detect elevations of fasting or postprandial glucose in capillary blood or venous plasma and is designed to detect any deterioration of glucose homeostasis as the pregnancy proceeds.

Having the mother complete self-monitoring of capillary blood glucose is critical and allows her to participate in the diabetes management process.

Blood Glucose: 4 to 7 times per day (before and 2 hours after each meal and before the evening snack).

Urinary glucose monitoring of the mother is not adequate or appropriate.

Urine ketone testing must be done to ensure adequate caloric intake.

Fetal Strategies

It is necessary to increase the level of surveillance of the fetus in women diagnosed with gestational diabetes.

The degree of cumulative risk that the clinician feels the fetus is exposed to will determine the:

* starting time for increased monitoring,

* frequency, and

* techniques used to analyze fetal well-being.

Nutritional Counseling

All women diagnosed with gestational diabetes should receive nutritional counseling by a registered licensed dietitian. The nutrition plan should be individualized based on maternal weight and height.

The nutritional meal plan should include the provision of adequate calories and nutrients to address the needs during the prenatal period and must be consistent with the established maternal glucose goals.

Women without medical or obstetrical contraindications should be encouraged to start or continue a program of moderate exercise.

Insulin Therapy

Insulin therapy is initiated when dietary management does not consistently maintain the fasting plasma glucose.

* < 5.8 M (< 105 mg/dl), and/or

* the two-hour postprandial plasma glucose < 6.7 M (< 120 mg/dl) on two or more occasions within a one- to two-week interval.

Additional therapeutic strategies include the following:

*        blood glucose self-monitoring is essential to meet therapeutic goals,
*        during pregnancy, oral agents are contraindicated,
*        moderate exercise may continue if the woman has had an active lifestyle,
*        noncaloric sweeteners may be used in moderation, and
*        women who have gestational diabetes should be encouraged to breastfeed.

Postpartum Follow-up Care

Women diagnosed with gestational diabetes should be followed after delivery to assess glucose intolerance. The initial evaluation should be completed six weeks after delivery and should include:

* a two-hour oral glucose tolerance test with a 75-g glucose load, unless either the fasting plasma glucose, or random blood glucose meets or exceeds criteria for diagnosis,

* a consultation with a registered dietitian, and

* discussion of contraception options - contraceptives with low doses of estrogen may be used safely in women with prior gestational diabetes whose postpartum glucose tolerance is normal.

Many women diagnosed with gestational diabetes will develop Type 2 diabetes. All women previously identified as having this disorder should continue to have follow-up evaluations at regular intervals during their entire lifetime. Stress the importance of weight control and to maintain
BMI of less than 25.

Diabetes Self-Management Training

Diabetes is unique among chronic health conditions because, to a large extent (90 percent), treatment depends upon self-management. The management of diabetes is a team effort. The patient is the primary team member, with the physician, certified diabetes educator, registered dietitian, and other health care professionals who play vital roles in the treatment of the illness. The importance of patient participation in a comprehensive outpatient self-management education program is critical to the treatment outcomes of this disease.

During the initial period of onset of the disease, diabetes self-management education is critical to the treatment and management of the illness and should be introduced within the first week of diagnosis.

Initial Self Management Training

A minimum of 10 to 12 hours of instruction should be provided to all patients within a continuous 12 month period of the initial diagnosis. It is preferable that instruction be provided within 12 weeks of the initial diagnosis.

Self-management education starts with an assessment of the individual’s educational needs that will assist in the planning of teaching/learning strategies and which will be the foundation of an education and lifestyle plan. Patient outcomes will be monitored for lifestyle changes and revised as necessary.

To be considered a quality diabetes self-management education program, the program must provide comprehensive instruction in the content areas that impact the target population and the participants enrolled. The curriculum, teaching strategies, and materials used should be appropriate for the audience and should consider:

* type and duration of diabetes,

* age,

* cultural sensitivity, and

* individual learning abilities and special educational needs.

The patient will need to be assessed by other health care professionals during the initial assessment phase. Professional team members that should be involved in self-management training include:

* certified diabetes educator - all patients,

* licensed, registered dietitian - all patients,

* exercise physiologist - if necessary,

* licensed mental health professional - if necessary, and

* social worker - if necessary.

If a certified diabetes educator and licensed registered dietitian are not used, a written explanation must be written in the patient’s chart.

Based on demographics and needs of the target population, the self-management education program should provide in-depth instruction in the following content areas.

Additional Self Management Training

After completing the initial training, individuals may need follow-up sessions. The type and frequency (individual or group) of follow-up will vary depending on medical need. Approval will be based on medical necessity as documented by the treating physician.

Diabetes Overview

The initial session should focus on the critical nature of this disease — stressing that diabetes can be serious and lead to life-threatening complications if not appropriately treated. Information needs to be provided that will enable the individual or parent to implement the treatment plan at home.

Areas for discussion should include:

* definition of the disease - including the different types of diabetes, prevalence of the disease and risk factors,

* basic pathophysiology of disease,

* reasons for treatment (insulin injections, oral medications, diet and exercise), and

* complications of the disease.

Medication

The daily administration of insulin injections or oral agents as prescribed is often essential to the successful treatment of diabetes. The goal of this session is to provide individuals (parents, other family members, significant others) with the necessary tools, skills and techniques to safely, comfortably, and accurately follow the prescribed treatment plan.

Areas for discussion should include:

* definition and purpose of insulin,

* the types of insulin,

* the importance of proper storage and inspection of insulin for possible changes (i.e., clumping, frosting, change in clarity or color),

* amount and times to administer insulin,

* injection site selection,

* discussion and demonstration of correct techniques for dose preparation, drawing up medication, injecting insulin and proper disposal techniques,

* syringe reuse,

* insulin pump therapy*,

* Training for insulin pump therapy initiation requires a comprehensive program of no less than
10 to 12 hours one-to-one training individualized to the patient’s ability and existing knowledge base at the time of referral.

* changing from no diabetes medications to any diabetes medication, or from oral diabetes medication to insulin within 12 months,

* the types of oral agents (sulfonylureas, meglitinides biguanides, alpha-glucosidase inhibitors and thiazolidinediones),

* relationship of blood glucose levels to exercise, food intake, stress, and reasons for adjustment to insulin dosages, oral agents,

* hypoglycemic reaction and treatment with glucagon,

* importance of family members and significant others knowing the proper administration of insulin and instruction in the use of glucagon, and

* management of sick days.

All individuals who are required to take insulin or oral hypoglycemic agents should carry diabetes alert jewelry or card in wallet that clearly identifies to others that they have diabetes and are required to use insulin or oral agents.

Monitoring and Use of Results

For individuals with diabetes, self-monitoring of blood glucose either by the individual or by a member of the health care team is an integral component in the treatment of this disease. Diabetes can only be effectively and safely managed through proper monitoring of blood glucose levels. The goal of this session is to ensure better glycemic control through proper self-monitoring techniques.

Areas for discussion should include:

* defining self-monitoring of blood glucose (SMBG),

* purpose and results of blood glucose monitoring are used to:

– help prevent hypoglycemia, and

– determine if adjustments to insulin, oral agents, nutrition and exercise are necessary to achieve and maintain target blood glucose levels,

* equipment used in self-evaluation of blood glucose levels,

* instruction in the correct method of testing (which should include the importance of having a meter that has been evaluated for accuracy),

* usual frequency and timing of glucose monitoring (may differ according to individual needs and treatment goals e.g., pregnant women or patients who are intensively treated),

* examples of suggested schedules for self- monitoring of blood glucose,

* examples of suggested insulin adjustments for twice-daily and other insulin regimens,

* common causes of SMBG monitoring errors,

* urine testing - appropriate use and limitations,

* ketone testing, when appropriate,

* studies or evaluations that may be necessary, and

* laboratory-performed monitoring tests.

For successful SMBG, the health care team must ensure that individuals:

* have appropriate technical guidance including psycho-social and family support,

* monitor blood glucose levels as prescribed in the treatment plan at a minimum of before meals and at bedtime,

* are proficient in reading and reporting test results accurately,

* understand how to replace their monitoring supplies,

* regularly meet with the health care team to review results of glycemic patterns, and

* consult with the health care team for changes in the insulin plan based on results.

Nutrition

Integral to the treatment and management of diabetes is proper nutrition. Nutrition is the most challenging aspect of this illness, and yet, the overall improvement of health outcomes is dependent on optimal nutrition.

The goal of this session is to assist individuals with diabetes in making changes in nutritional habits that will lead to improved metabolic control. Medical nutrition therapy should be individualized with consideration given to usual eating habits, exercise patterns, insulin regimen, oral agents, cultural diversity, and other lifestyle factors. Recommendations should be developed to address treatment goals and desired outcomes.

Areas for discussion include:

* patient assessment (clinical data, dietary history, nutrient intake and social history),

* goal setting,

* nutrition meal plan,

* weight loss, and

* evaluation.

The importance of monitoring metabolic guidelines to ensure successful outcomes must be emphasized and should include a discussion of:

* blood glucose,

* hemoglobin A1c levels,

* lipids,

* blood pressure,

* body weight, and

* quality of life issues.

Options for regimen adjustments based on self-monitoring of blood glucose results (SMBG) are critical to this discussion.

A discussion of the guidelines used in calculating daily calorie requirements should be reviewed as well as the different food groups (based on the current Dietary Guidelines for Americans and the Food Guideline Pyramid as well as recommendations from the American Dietetic Association and the American Diabetes Association). Suggestions to improve current food choices should be provided based upon an assessment of individual needs and desired metabolic outcomes. The following nutritional issues should be addressed:

* functions of energy nutrients (carbohydrates, proteins and fats) and their effect on metabolic outcomes (blood glucose levels, lipid levels, blood pressure and weight),

* functions and effects of other nutrients (fiber, sodium, micronutrients - vitamins and minerals and nutritive and non-nutritive sweeteners), and

* function, effects, and guidelines for appropriate use of alcohol.

Additional nutritional considerations covered in this session should include:

* timing and spacing of meals and snacks,

* how to read food labels,

* grocery shopping tips for preparing meals for individuals with diabetes,

* sick day management,

* growth years,

* food adjustment for exercise,

* pregnancy,

* lactation,

* obesity management, and

* eating disorders.

Emphasize the relationships between nutrition, exercise, medication, and blood glucose levels.

Immunizations

Discuss the importance for individuals having diabetes to follow recommended immunization schedules. Areas to be discussed include:

* rationale for obtaining flu shot and pneumococcal vaccinations,

* the benefits of immunizations,

* the low risks of immunization interventions, and

* the impact on the care of people with diabetes.

Prevention, Detection and Treatment
of Acute and Chronic Complications

Areas for discussion should include:

* definitions, examples, and treatment of acute conditions (e.g., hypoglycemia and hyperglycemia, diabetic ketoacidosis when ill), and

* chronic conditions (retinopathy, nephropathy, neuropathy, macrovascular complications, limited joint mobility, and in children, subtle growth abnormalities). The following components should be assessed for each condition:

– incidence,

– causes,

– symptoms,

– role of SMBG,

– short- and long-term effects and complications,

– treatment,

– preventive strategies, and

– review of a recommended schedule for evaluation (monthly, six months, annually which may vary according to individual needs).

In this section, a discussion of sick day management should occur. Illness can make the management of diabetes more difficult. Patients must understand that continued adherence to the following is critical:

* importance of medical alert identification,

* importance of continued blood glucose and ketone testing,

* importance of timely communication with diabetes care provider during illnesses that affect blood glucose levels or absorption of nutrients and fluids,

* need for ongoing insulin treatment, with possible dose adjustment based on blood glucose data,

* maintaining food and fluid intake, and

* seeking prompt medical attention when one has:

– fever > 100 degrees F,

– persistent diarrhea,

– vomiting and the inability to take (retain) fluids for > four hours,

– blood glucose levels that are difficult to control and/or if ketones are found in urine,

– severe abdominal pain,

– any noticed lower extremity or foot symptoms,

– other unexplained symptoms, and/or

– illness that continues over a 24-hour period.

Other medical conditions that should be discussed include:

* poor glycemic control, as evidenced by a hemoglobin A1c level of 8.0% or more in 90 days before attending the training,

* a change in treatment regimen from no diabetes medications to any diabetes medication, or from oral diabetes medication to insulin within 12 months, and

* insulin pump therapy.

Exercise and Activity

As with nutrition, proper exercise impacts metabolic control of blood glucose. The goal of this session is to stress the importance of an individualized exercise regime that is closely monitored and one that will become an integral component of the treatment plan. Given appropriate guidelines, people with diabetes can exercise safely. Exercise should be prescribed in much the same way as the nutritional plan and insulin. Areas for discussion should include:

Importance of An Individualized Exercise Plan

The exercise plan will vary depending on interest, age, general health and level of physical fitness. The key to success is for the plan to be individualized.

Reducing Exercise Risk

Exercise plans must be preceded by a pre-exercise medical evaluation, well-supervised and planned so that an individual progresses from low to more strenuous levels of exertion.

Guidelines for Safe Exercise Including Preparing for Exercise
(Adjustment of Food and Insulin)

The following general exercise guidelines for individuals with diabetes should be discussed:

* the use of proper and well-maintained footwear and identification of other appropriate protective equipment,

* exercise should be avoided in extreme heat or cold temperatures,

* feet and shoes should be inspected daily after completion of exercise, and

* patients should discontinue exercise during periods of poor metabolic control.

Benefits of Exercise

Increased activity may help to:

* reduce risk factors for cardiovascular disease,

* improve insulin sensitivity,

* help control weight, and

* improve sense of well-being.

Glycemic Response to Exercise

As part of the exercise regime, individuals must include self-monitoring of blood glucose levels which will determine whether it is necessary to make adjustments to the patient’s diet or drug therapy (this is necessary for both oral medications or insulin). The site of insulin injection, and the timing, may influence the glucose response to exercise.

Individuals with diabetes should be taught to avoid exercise in the presence of urinary ketones or high blood glucose levels.

Continue to emphasize the relationships among nutrition, exercise, medication, and blood glucose levels.

Stress and Psycho-Social Adjustment

Individuals diagnosed with a chronic illness like diabetes will very likely exhibit feelings of fear, anger, and denial of the disease. Knowing that the health outcomes of the illness are dependent on their own behavior and self-management can be frustrating and involve many changes to an individual’s lifestyle. The level of anxiety and frustration may indirectly affect glucose control if the treatment regime and plan are not followed.

Remember diabetes affects the entire family, friends, and the individual's social network.

The goal of this session is to introduce ways to address the psycho-social impact of this disease.

Areas for discussion should include:

* factors that cause emotional distress at diagnosis,

* importance of family, teachers, and co-workers knowing about the illness, how they can support adherence to the treatment plan goals and how to respond in emergency situations,

* strategies to improve and maintain adherence to treatment plan,

* examples of coping skills and stress reduction techniques should be highlighted,

* benefits of individual (and/or) group and family counseling individuals may experience depression and anxiety disorders. Teenage girls and young women may have eating
disorders, and

* the detrimental effects of substance abuse for individuals with diabetes.

As in other sessions, it is important to focus on those "special areas" of concern that impact the target audience. Remember some individuals may need to be referred for further counseling (individual and/or group) to receive guidance and support in coping with their illness.

Children

Diagnosis of diabetes in children impacts the parents as well as the child. Usually, the first year after diagnosis is the hardest on the family. Parents will have concerns regarding their child's caretakers
(e.g., preschool teacher, baby-sitter) and how their child will be treated by other children.

A child's responsibility for self-involvement will increase as the child grows both developmentally and emotionally. Stress to the parents not to increase too much self-care too quickly.

Adolescents

Peer influences, family support and supervision are critical in adhering to the treatment plan and to glycemic control. During the teen years, children will need to feel that they have some control over the treatment regime. Of critical concern to adolescents is the acceptance by their friends in spite of their diabetes. Social and sports events play major roles during the adolescent years.

As previously mentioned, eating disorders in teenage girls and young women may occur. Symptoms include a history of unstable or poor metabolic control, recurrent ketoacidosis or recurrent severe hypoglycemia, growth retardation, delay of puberty and/or amenorrhea.

Young Adults

For adults, coping with diabetes may raise issues regarding marriage, pregnancy and/or having a family, and issues relating to work and financial concerns.

Older Adults

Diagnosis of diabetes at an older age may be especially difficult for those already coping with retirement, loss of physical function, managing on a lower income level, and loss of a spouse or friends. Facing one's own mortality can be frightening.

Foot, Skin, and Dental Care

The goal of this session is to provide individuals with a better understanding of the need for proper and ongoing foot, skin, and dental care.

Individuals who have diabetes may experience infections in many areas, including gums, skin, and feet. This is caused by high glucose levels that may lead to bacterial growth that may result in infections.

A critical component of the treatment regime is to seek routine care to keep teeth, gums, and skin clean and to check feet for cuts and red or discolored areas. Areas for discussion should include:

* incidence,

* causes,

* symptoms,

* role of SMBG,

* short- and long-term effects and complications,

* treatment,

* preventive strategies (including daily foot inspection by the patient) and the use of preventive foot wear, and

* review of a recommended schedule for evaluation (monthly, six months, annually which may vary according to individual needs).

Use of Health Care Systems and Community Resources

Individuals with diabetes need to be knowledgeable and know how to access available medical services and community resources. The goal of this session is to identify those community resources and organizations that can assist the individual and the family with medical and psycho-social needs. Areas for discussion should include:

* importance of providing accurate telephone numbers of health care team members and emergency services for family, friends, and other significant individuals,

* identification and explanation of available community resources for supplies, services, information, and support groups, and

* social service/medical service agencies within the community that may be able to assist the individual/family with specific needs (e.g., Children’s Medical Services, community mental health agencies, local medical society).

Reference List

American Diabetes Association. (1996). Diabetes 1996 Vital Statistics. Alexandria, VA: American Diabetes Association.

American Diabetes Association. (2000) Type 2 diabetes in children (Consensus conference). Diabetes Care.

American Diabetes Association. (1996). Self-monitoring of blood glucose (Consensus Statement). Diabetes Care, 19 (Suppl. 1), S62-S66.

American Diabetes Association: Treatment of hypertension in diabetes (Consensus Statement). (1996). Diabetes Care, 19 (Suppl. 1), S107-S113.

American Diabetes Association. (2001). Diabetic nephropathy (Position Statement). Diabetes Care, 24 (Suppl. 1), S69-S72.

American Diabetes Association. (2001). Foot care in patients with diabetes mellitus (Position Statement). Diabetes Care, 24 (Suppl. 1), S56-S57.

American Diabetes Association. (2001). Gestational diabetes mellitus (Position Statement). Diabetes Care, 24 (Suppl. 1), S77-S79.

American Diabetes Association. (2001). Immunization and the Prevention of Influenza and Pneumococcal Disease in People With Diabetes (Position Statement). Diabetes Care, 24 (Suppl. 1), S99-S101.

American Diabetes Association. (2001). Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus(Position Statement). Diabetes Care, 24 (Suppl. 1), S5-S20.

American Diabetes Association: National standards and review criteria for diabetes self-management education programs. (2001). Diabetes Care, 24 (Suppl. 1), S126-S130.

American Diabetes Association. (2001). Nutrition recommendation and principles for people with diabetes mellitus (Position Statement). Diabetes Care, 24 (Suppl. 1), S48-S50.

American Diabetes Association. (2001). Screening for diabetic retinopathy (Position Statement). Diabetes Care, 24 (Suppl. 1). S73-S76.

American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). (2001). Diabetes Care, 24 (Suppl. 1), S33-S43.

Bennett, P. H., Haffner, S., Kasiske, B. L., Keane, W. F., Mogensen, C. E., Parving H-H., Steffes, M. W., & Striker, G. E. (1995). Screening and management of microalbuminuria in patients with diabetes mellitus. American Journal of Kidney Disease, 25, 107-112.

Centers for Disease Control and Prevention. (1994). Diabetes in the United States: A strategy for prevention. Atlanta: U. S. Department of Health and Human Services, Public Health Service.

Clement, S. (1995). Diabetes self-management education (Technical Review). Diabetes Care, 18, 1204-1214.

The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. (1993). New England Journal of Medicine, 329, 977-986.

The Diabetes Control and Complications Trial Research Group: The relationship of glycemic exposure (HbA_1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. (1995). Diabetes, 44, 968-983.

The Diabetes Control and Complications Trial Research Group: The lifetime benefits and costs of intensive therapy as practiced in the Diabetes Control and Complications Trial. (1996). JAMA, 276, 1409-1415.

Franz, M. J., Horton, E. D., Bantle, J. P., Beebe, C. A., Brunzell, J. D., Coulston, A. M., Henry, R. R., Hoogwerf, B. J., Stacpoole, P. W. (1994). Nutrition principles for the management of diabetes and related complications (Technical Review). Diabetes Care, 17, 490-518.

Kitzmiler, J. L., Buchanan, T. A., Kjos, S., Combs, C. A., & Ratner, R. (1996). Preconception care of diabetes, congenital malformations, and spontaneous abortions (Technical Review). Diabetes Care, 19, 514-541.

Mogensen, C. E., Keane, W. F., Bennett, P. H., Jerums, G., Parving, H-H., Passa, P., Steffes, M. W., Striker, G. E., & Viberti, G. C. (1995). Prevention of diabetic renal disease with special reference to microalbuminuria. Lancet, 346, 1080-1084.

National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (1995). Diabetes in America. (2^nd ed.). Washington, DC: U. S. Government Printing Office. (NIH publication. No. 95-1468).

Nutrition recommendations and principles for people with diabetes mellitus (Position Statement). (2001). Diabetes Care, 24 (Suppl. 1), S44-S47.

Ohkubo, Y., Kishikawa, H., Araki, E., Miyata, T., Isami, S., Motoyosyi, S., Kojima, Y., Furuyoshi, N., & Shichiri, M. (1995). Intensive insulin therapy prevents the progression of diabetic microvascular complication in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective six-year study. Diabetes Research and Clinical Practice, 28,103-117.

O’Sullivan, J. B., & Mahan, C. M. (1964). Criteria for the oral glucose tolerance test in pregnancy. Diabetes, 13, 278-285.

Raskin, P. (Ed.). (1994). Medical management of non-insulin-dependent (Type II) diabetes (3^rd ed.). Alexandria, VA: American Diabetes Association.

Rubin, R., Altman, W., & Mendelson, D. (1994). Health care expenditures for people with diabetes mellitus, 1992. Journal of Clinical Endocrinology and Metabolism, 76(4), 809A-809F.

Santiago, J. V. (Ed.). (1994). Medical management of insulin-dependent (Type I) diabetes (2^nd ed.). Alexandra, VA: American Diabetes Association.

Schafer, R., Bohannon, B., Franz, M. J., Freeman, J., Holmes, A. McLaughlin, S., Haas, L., Kruger, D., Lorenz, R., & McMahon, M. (1997). Translations of the diabetes nutrition recommendations for health care institutions (Technical Review). Diabetes Care, 20, 96-105.

U. S. Department of Agriculture. (1996). The Food Guide Pyramid. Hyattsville, MD: USDA Human Nutrition Information Service.

U. S. Department of Agriculture, U. S. Department of Health and Human Services. (2000). /Nutrition and your health: Dietary guidelines for Americans (5^th Ed.). USDA Human Nutrition Information Service, Home and Garden Bulletin, 252.

Appendices

Center for Disease Control and Prevention (CDC) Growth Charts for the United States - Boys and Girls

Body Mass Index (BMI) Table

Patient Chart Flow Sheet

Quick Reference Cards

Minimum Standards of Care for Children with Diabetes

Office Visits

Criteria that Suggest Children or Adolescents have Type 2 Diabetes

Treatment Goals for Children with Type 2 Diabetes

Diabetes Outpatient Care for Adults

Aspirin Therapy

Renal Evaluation

Initial Self Management Training

Immunizations

Prevention, Detection and Treatment of Acute and Chronic Complications

Appendices

Minimum Standards of Care
for Children with Diabetes

Criteria that Suggest Children or Adolescents have
Type 2 Diabetes

Prevention, Detection and Treatment
of Acute and Chronic Complications