Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation

Publication date:
January 1, 1991

All the information in this book was current at the time of publication. However, medical knowledge, research, and practice advance rapidly, so we recommend that readers consult physicians directly involved in their care for the latest information.

Table of Contents

• Foreword
• Preface
• Benefits of Blood Glucose Control Confirmed - (Supplement)
• Psychosocial Problems
• Acute Glycemic Complications
  • Diabetic Ketoacidosis; Background
  • Hyperglycemic Hyperosmolar Nonketotic Coma
  • Hypoglycemia
  • Teaching Patients to Avoid Acute Glycemic Complications
• Adverse Outcomes of Pregnancy
  • Pregestational and Gestational Diabetes; Background
  • Caring for the Patient With Pregestational Diabetes
  • Caring for the Patient With Gestational Diabetes
• Periodontal Disease
• Eye Disease
• Kidney Disease
• Cardiovascular Disease
• Neuropathy
• Foot Problems
• Appendix A, Office Guide
• Table 1:Clinical Manifestations of Eye Diseases
• Table 2: Example of an Office Guide
• Figure 1: Natural history of diabetic nephropathy in persons with insulin-dependent diabetes mellitus
• Acknowledgments
• Point of Contact for this Document

Foreword

The 1982 publication of The Prevention and Treatment of Five Complications of Diabetes: A Guide for Primary Care Practitioners was an initial attempt to provide straightforward and practical information that primary care practitioners could immediately apply in their practice in the diagnosis and prevention of complications of diabetes. In the eight years since that publication was released, over 200,000 copies have been distributed. The emphasis on early application of currently available preventive measures or treatments has resulted in the widespread use of the document.

The scope of the present revised edition has been broadened to cover nine complications of diabetes and the recommendations for the previous five. We anticipate continued widespread use of this guide in assisting practitioners in the care of their patients with diabetes. The recommendations are clear, practical, and based upon scientific evidence, and they can be generally implemented in an office practice. We believe that they are conceptually consistent with the American Medical Association's new emphasis on practice parameters.

Although this publication is meant to provide freestanding and practical assistance in an office practice, the most appropriate use is in continuing education programs and workshops. In these settings, the practical application of the recommendations can be discussed and barriers to their application in individual practices overcome.

We congratulate the Centers for Disease Control in its efforts to update this guide and wish it the same success as the previous edition.

Charles M. Clark, Jr., M.D.
Indiana University School of Medicine
Indianapolis, Indiana

Preface

This publication is designed to help the primary care practitioner in the day-to-day management of patients with diabetes. The recommendations relate to the prevention, detection, and treatment of the major complications of diabetes. The emphasis is on early application of currently available measures that, if systematically applied, may reduce the incidence or severity of these complications. Because of the need for brevity and practicality, we have neither discussed areas of controversy nor provided in-depth discussions of pathophysiology and the scientific rationale for treatment.

An office guide is included as an appendix. The office guide is a brief synopsis of the recommendations contained in the body of the text and is designed so that it may be photocopied and placed in the patient's medical record.

A companion publication entitled Take Charge of Your Diabetes: A Guide for Patients is available. It is written in nontechnical language and emphasizes the same preventive measures and treatments. The sequence of the chapters corresponds with the sequence in this document.

William H. Herman, M.D.
University of Michigan Medical Center
Ann Arbor, Michigan

Appendix A, Office Guide

The office guide is a brief synopsis of the recommendations contained in the body of the text and is designed so that it may be photocopied and placed in the patient's medical record.

(Table 2) Example of an office guide.

Acknowledgments

This publication was prepared by the Department of Health and Human Services, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes, under the general editorship of William Herman: Alacia Lyons was the project coordinator.

The following persons prepared chapters of this publication: Jerry Cavallerano, Ralph DeFronzo, Steven Gabbe, Alan Jacobson, Marvin Levin, Michael Pfeifer, Philip Raskin, Susan Szpunar, and Fred Whitehouse.

The following persons served as primary reviewers of the draft chapters: Harry Bennert, Stephen Corbin, Donald Coustan, Daniel Cox, Allen Drash, Catherine Feste, Douglas Greene, William Herman, Ronald Klein, Robert Luke, David Nathan, Pasquale Palumbo, Roger Pecoraro, Anthony Rizzo, Peter Savage, and F. William Wagner, Jr.

The following organizations have lent their support in the development of this publication: the American Association of Diabetes Educators, the American Diabetes Association, the American Dietetic Association, the Juvenile Diabetes Foundation, the National Diabetes Advisory Board, and the Technical Advisory Committee of the Division of Diabetes Translation.

The following persons have also assisted in the preparation of this publication: Robert Anderson, David Ballard, Elizabeth Barrett-Connor, Diane Bild, Alton Brown, Frank DeStefano, Joycelyn EIders, Mary Anne Farrell, Catherine Feste, Florence Fiori, Earl Ford. Richard Hamman, Maureen Harris, Carlos Hernandez, Saunders Hupp, Sharon Johnson, William Jubiz, Richard Kahn, Barbara Klein, Raymond Kuehne, Daniel Lorber, Maria Ludi, James Marks, Robert Moran, Ben Muneta, Jeffrey Newman. John O'Brian, James Pichert, Gayle Reiber, Alice Ring, William Robinson, Dawn Satterfield, Richard Scheffler, Maria Segarra, Stephen Sepe, Mohamed Shakir, Karl Sussman, Frank Vinicor, John Waller, Jr., Scott Wetterhall, Julie Will, and Deborah Wingard.

The editor acknowledges with gratitude Charles M. Clark, Jr., Dorothy Gohdes, and Fran Wood for contributing critical reviews of the entire manuscript and Kelly Fearer for her secretarial assistance.

Division of Diabetes Translation, Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia

Point of Contact for this Document:

To request a copy of this document or for questions concerning this document, please contact the person or office listed below. If requesting a document, please specify the complete name of the document as well as the address to which you would like it mailed. Note that if a name is listed with the address below, you may wish to contact this person via CDC WONDER/PC e-mail.
DIVISION OF DIABETES TRANSLATION
NATIONAL CTR FOR CHRONIC DISEASE PREVENTION & HLTH PROM CDC (NCCDPHP)
1600 Clifton Rd NE, MS:(k-10)
Atlanta, GA 30333

Table 1

Table 1.  Clinical Manifestations of Eye 

          Diseases
================================================
Nonproliferative Diabetic Retinopathy

   Nonproliferative Diabetic Retinopathy

   -  Retinal microaneurysms.
   -  Occasional blot hemorrhages.
   -  Hard exudates.
   -  One or two soft exudates.

   Preproliferative Diabetic Retinopathy

   -  Presence of venous beading.
   -  Significant areas of large retinal 

      blot hemorrhages.
   -  Multiple cotton wool spots (nerve fiber 

      infarcts).
   -  Multiple intraretinal microvascular 
      abnormalities.

   Prolliferative Diabetic Retinopathy

   -  New vessels on the disc (NVD).
   -  New vessels elsewhere on the retina (NVE).
   -  Preretinal or vitreous hemorrhage.
   -  Fibrous tissue proliferation.

   High-Risk Proliferative Diabetic Retinopathy

   -  NVD with or without preretinal or vitreous 

      hemorrhage.
   -  NVE with preretinal or vitreous hemorrhage.

   Dibetic Macular Edema

   -  Any thickening of retina <2 disc diameters 
      from center of macula.

   -  Any hard exudate <2 disc diameters from 
      center of macula with associated thickening 
      of the retina.

   -  Any nonperfused retina inside the temporal 
      vessel arcades.

   -  Any combination of the above.

Table 2

      Table 2. Example of an Office Guide
===========================================
            Office Guide

Patient's Name:____________________________

Address:___________________________________

Phone: home (    )_______________________
       work (    )_______________________

Date of birth:   _______/_______/________
                  mo      day     year

Year of diagnosis:_______________________

Type od diabetes: IDDM___ NIDDM___ 
Other________________________

Diet:  calories______________________
  meals and snacks (circle)
       breakfast  snack   lunch   snack   
       dinner   snack   snack

Exercise:     type__________  
              frequency_______________/week
              duration______minutes  
              time of day____________________

Monitoring:   blood glucose_____  urine glucose_____  
               urine ketones_____
              frequency__________________________/day

Oral hypoglycemia agent:_____________________________

Insulin:_____________________________________________

Other medications:___________________________________

Figure 1

A text version of this image is available.

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This page last reviewed May 17, 2001.

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes Translation