More Resources

• Veterans Administration (VA) Foot Assessment Tool (pdf)
• Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
  American Diabetes Association, Inc.

Summary of 2006 Changes

The Advisory Group reviewed these guidelines in between November 2005 and May 2006, and adopted the following changes:

• A new Emerging Issues section introduces three important emerging topics related to patient care: depression, the effect of a periodontal inflammation on glycemic control, and targeted screening for diabetes. Although specific guidelines on these topics are not proposed, these issues merit serious consideration by health systems involved in quality improvement efforts.
• Individual adult guidelines for angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor  blocker (ARB), blood pressure screening, lipid screening, tobacco use assessment and aspirin prophylaxis have been grouped into a new Cardiovascular Health section.
• Guidelines to assess quality of care for pediatric patients have been added.
• Caution statements regarding use of potentially teratogenic medications have been added where appropriate in the adult guidelines.
• The phrase “medical record” has been substituted for “chart.”
• Levels of evidence for specific guidelines are indicated in each section, using the levels of evidence stated in the American Diabetes Association 2006 clinical practice recommendations as a guide.
• References have been updated.

Specific Guideline Changes:

• A revised adult guideline recommends that an ACE inhibitor/angiotensin receptor blocker be initiated for all people with diabetes who are >55 years of age and have at least one other cardiovascular risk factor.
• Angiotensin receptor blockers are recognized as interchangeable with ACE inhibitors for treatment of high blood pressure, microalbuminuria and overt nephropathy.
• The definition of microalbuminuria in adults has been changed to one early-morning albumin:creatinine ratio > 30 (μg albumin / mg creatinine).
• Adult low-density lipoprotein (LDL) risk categories have been removed, and treatment with statins is recommended if LDL >130 mg/dl.
• The recommended interval for HbA_1c testing in adults is 6 months for both type 1 and type 2 diabetes.
• Patient education recommendations (now titled “Patient Education and Lifestyle Modification”) include a reminder that education should include information regarding the importance of physical activity and monitoring of total carbohydrate intake and calories. An associated body mass index (BMI)-related quality measure has been added.
• A revised guideline recommends that a schedule of regular foot examinations be started directly after diagnosis for adult patients with type 1 and type 2 diabetes.
• For patients without retinopathy, a revised guideline recommends that eye examinations be performed or interpreted by an ophthalmologist or optometrist. New recommendations have been added for prenatal eye examination and counseling on diabetic retinopathy related to pregnancy. The definition of blindness has been updated.
• Oral/dental guidelines now include a recommendation for all adults with diabetes to be referred to a dentist for comprehensive oral evaluation at diagnosis, for oral screening at least every 6 months, and for immediate treatment of an expanded list of oral/dental conditions. Patients without access to regular dental care should receive oral screening and self-care education from their primary care provider every 6 months until they can see a dentist.