Table 1.
Major changes in American Diabetes Association diagnostic and treatment recommendations, 1979 to 2020
| Date & Source |
Classifications | Who to Screen | Recommended Tests | Dx & Tx Thresholds | Recommended Tx |
|---|---|---|---|---|---|
| (National Diabetes Data Group 1979) | NEW TERMS: • IGT • IDDM & NIDDM DISCONTINUE TERM: • DROPS: “PreDM” |
• DM Sx (polyuria, polydipsia, ketonuria, rapid weight loss) • 1st degree relative with DM • Had baby >9lbs • Obese • Racial/Ethnic groups with high DM prevalence |
• FPG (test twice) • GTT |
• Normal: FPG <115 • DM: - FPG >140 - GTT >200 • IGT: - FPG >115 |
• IDDM require insulin • NIDDM may require insulin or oral meds • IGT: Weight loss recommended (no medications) |
| (ADA 1987, 1989) | No Major Changes | ADD • High-risk racial groups are: American Indian, Hispanic, or Black • >40 yo with “risk factors” • Previous IGT |
No Major Changes | No Major Changes | • MNT recommended as primary treatment approach for NIDDM |
| (ADA 1994) | No Major Changes | No Major Changes | No Major Changes | No Major Changes | IDDM: goal near normal (FPG <115) • NIDDM: diet and exercise; meds for some • Individual Tx goals set jointly with patient |
| (ADA 1997) | DISCONTINUE TERMS: • IDDM & NIDDM ADD TERMS: • Type 1 DM & Type 2 DM • IFG & IGT • PreDM is early stage of DM |
ADD: • Everyone >45 yo. • Any age with “risk factors” • >120% ideal weight or BMI >27 • Screen to identify PreDM and asymptomatic DM2 |
ADD: • RPG (2nd test, different day) • GTT not recommended: costly & impractical |
NEW Dx VALUES: • Normal: FPG <110 • DM: - FPG >126 - GTT >200 • PreDM, IFG & IGT: - FPG >110 - RPG >200 +Sx - GTT >140 |
• Goal is tight control, for DM1 and some DM2, using diet and exercise and combinations of rapid, short and longterm. insulins |
| (ADA 2002, 2003) | CHANGE TERMS: • IFG & IGT now called PreDM |
CHANGE: • BMI >25 |
ADD: • A1c to monitor Tx • FPG preferred for Dx |
New Tx VALUES - A1c >8 for Tx - A1c <7 Tx goal - A1c <6 Normal |
• Weight. loss more effective than meds for PreDM |
| (ADA 2004) | No Major Changes | ADD: BMI to screen differs by ethic group |
ADD: • A1c NOT for Dx use; only to monitor Tx. |
CHANGE: • Normal: FPG <100 • PreDM: -FPG > 100 |
• Diet and exercise recommendations expanded |
| (ADA 2007) | No Major Changes | No Major Changes | No Major Changes | No Major Changes | • ADD: Multi-Drug Algorithm for DM2 • Diet and exercise changes described as hard to sustain • MNT recommendations shortened • Drugs are NOT recommended for PreDM, due to possible side effects, and lack of evidence for efficacy in DM2 prevention |
| (ADA 2008, 2009) | No Major Changes | No Major Changes | No Major Changes | No Major Changes | • CHANGE: New DM2 Drug Algorithm (more elaborate/complex) • Use meds for DM2 to reach goal levels ASAP • Metformin recommended for PreDM to prevent developing into DM2 |
| (ADA 2010) | No Major Changes | ADD: • Screen regularly if A1c >5.1 • To identify those at future risk for DM2 and those in asymptomatic phase of DM2 |
CHANGE: • A1c for Dx • 2nd test recommended optional • Recommends A1c as lab test only • POC A1c test not acceptable for Dx |
NEW Dx VALUES: • DM Dx: - A1c >6.5 • PreDM Dx: - A1c 5.7–6.4 - FPG >100 |
• At Dx for DM2 begin drug therapy • Consider bariatric surgery to manage DM if BMI >35 |
| (ADA 2011) | No Major Changes | No Major Changes | No Major Changes | CHANGE Tx GOALS: • A1c <6.5 if no HG • A1c <8 if severe HG |
No Major Changes |
| (ADA 2014) | No Major Changes | No Major Changes | ADD: • A1c levels vary with race/ethnicity |
• No Major Changes | • REVISE: Drug Algorithm with new meds • Adds obesity medications chart |
| (ADA 2017) | No Major Changes | No Major Changes | No Major Changes | CHANGE Tx GOALS: • A1c <6.5 • A1c <7 if HG Sx • A1c <8 if serious HG or short life expectancy |
• CHANGE: Drug Algorithm revised to stress sequential med. addition. • Revise diet and exercise recommendations • ADD Table of medication costs |
| (ADA 2018a, 2018b) | • Community screening for PreDM acceptable with referral system | No Major Changes | • A1c for Dx requires lab and 2nd test | No Major Changes | • ADD Tables with drug benefits, costs and side effects costs • Stress diet and exercise for PreDM • Metformin for PreDM if BMI >35 or <60yo |
| (ADA 2019a, 2019b) | No Major Changes | No Major Changes | CHANGE • Dx with 2nd test using same blood sample |
No Major Changes | • Adjust glycemic targets, as needed for individual |
| (ADA 2020a, 2020c) | • Includes ADA/CDC PreDM Risk Test | No Major Changes | No Major Changes | No Major Changes | • CHANGE: Drug Algorithm revised to simplify cost/benefit assessment • Expansion of discussion of manage HG with glycemic control medications |
A1c, glycated hemoglobin; DM, diabetes mellitus; DM1, type 1 diabetes mellitus; DM2, type 2 diabetes mellitus; Dx, diagnosis; FPG, fasting plasma glucose; GTT, glucose tolerance test; HG, hypoglycemia; IDDM, insulin dependent diabetes mellitus; IFP, impaired fasting glucose; IGT, impaired glucose tolerance; IGT, impaired glucose tolerance; MNT medical nutrition therapy ; NIDDM, non-insulin dependent diabetes mellitus; POC, point of care; RPG, random plasma glucose; Sx, symptoms; Tx, treatment