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Cited by 2,167Diabetes Management and ResearchDiabetes Treatment and ManagementDiabetes Management and Education

Standards of Medical Care in Diabetes—2009

Open access
American Diabetes Association·2009·Diabetes Care
DOI 10.2337/dc09-s013PMC PMC2613589
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Abstract

The recommendations in this article are based on the evidence reviewed in the following publication: Standards of Care for Diabetes (Technical Review).

AI snapshot

Written from the paper’s full text.

TL;DR

The American Diabetes Association's 2009 Standards of Medical Care in Diabetes is a comprehensive clinical practice guideline covering classification, diagnosis, screening, treatment targets, complication prevention, and care in special populations and settings. It grades each recommendation (A, B, C, or E) by strength of supporting evidence and synthesizes RCT, meta-analytic, and observational data on glycemic, blood pressure, and lipid management.

Key findings

  • Glycemic goal for most nonpregnant adults is A1C <7% (A); less stringent goals are appropriate for patients with severe hypoglycemia history, limited life expectancy, advanced complications, or extensive comorbidity (C), and lower goals may be considered for selected patients without significant CVD (B).
  • Intensive lifestyle intervention reduces incident type 2 diabetes by ≥58% after 3 years; metformin, acarbose, orlistat, and TZDs also reduce incident diabetes to varying degrees, with metformin recommended only for very-high-risk individuals (combined IGT and IFG, obese, under 60).
  • In ACCORD (10,251 participants), intensive glycemic control was halted for excess mortality (1.41%/year vs. 1.14%/year; HR 1.22 [95% CI 1.01–1.46]); ADVANCE (11,140 participants) showed significant reduction in the combined microvascular/macrovascular primary endpoint (HR 0.90 [0.82–0.98], P = 0.01), driven by microvascular events, with no mortality difference; VADT (1,791 participants) showed a nonsignificant primary outcome reduction (HR 0.87 [0.73–1.04], P = 0.12).
  • Care is suboptimal: only 37% of adults with diagnosed diabetes achieved A1C <7%, 36% had blood pressure <130/80 mmHg, 48% had total cholesterol <200 mg/dl, and only 7.3% achieved all three goals.

Methods

  • Design: ADA clinical practice guideline ("Standards of Medical Care"), with recommendations graded A, B, C, or E to codify the level of supporting evidence; recommendations span screening, diagnosis, and therapeutic actions.
  • Evidence base: synthesis of randomized controlled trials (e.g., DCCT, UKPDS, DPP, ACCORD, ADVANCE, VADT, Look AHEAD), meta-analyses, and observational/epidemiologic studies, plus referenced ADA consensus and position statements.
  • Key quantitative anchors cited include the ADAG trial (507 adults; A1C–mean glucose correlation r = 0.92), the HAPO study (~25,000 pregnant women), a 26-week CGM trial in 322 type 1 patients (0.5% A1C reduction in adults ≥25 years), and a bariatric surgery meta-analysis (78% diabetes resolution).

Limitations

  • Stated in the paper: the ACCORD excess-mortality cause "has been difficult to pinpoint," with hypoglycemia, weight gain, drug effects, and intervention intensity all plausible but not established as causative; the bariatric surgery RCT had only 60 subjects (13 with BMI <35 kg/m²), limiting generalizability; preconception care studies were self-selected rather than randomized, so lower malformation rates cannot be fully attributed to the intervention.
  • Stated in the paper: evidence for A1C lowering with CGM is less strong in children, teens, and younger adults; the appropriate interval between diabetes screening tests "is not known"; and the role of continued albuminuria surveillance after microalbuminuria diagnosis and ACE inhibitor/ARB initiation "is unclear."
  • Evident from the text: many recommendations carry an E grade (expert consensus/opinion) rather than trial evidence, and the document does not describe a systematic literature search or evidence-appraisal methodology, so recommendations reflect expert panel judgment as well as trial data.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2337/dc09-s013

Cites

Statistics

Nothing to recompute.

Claims the paper makes

0 of 441 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    The appropriate interval between tests for pre-diabetes and diabetes is not known.

    “The appropriate interval between tests is not known (17).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Johnson SL, Tabaei BP, Herman WH: The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U.S. population 45–74 years of age. Diabetes Care 28:307–311, 2005 source

      Not checked in the free run.

  • Findingcitation

    A larger 26-week randomized trial of 322 type 1 patients showed that adults age 25 years and older using intensive insulin therapy and CGM experienced a 0.5% reduction in A1C (from ∼7.6 to 7.1%) compared with usual intensive insulin therapy with SMBG.

    “A larger 26-week randomized trial of 322 type 1 patients showed that adults age 25 years and older using intensive insulin therapy and CGM experienced a 0.5% reduction in A1C (from ∼7.6 to 7.1%) compared with usual intensive insulin therapy with SMBG (38).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group: Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 359:1464–1476, 2008 source

      Not checked in the free run.

  • Interpretationreasoning

    Pre-diabetes and diabetes meet established criteria for conditions in which early detection is appropriate.

    “Although the effectiveness of early identification of pre-diabetes and diabetes through mass testing of asymptomatic individuals has not been definitively proven (and rigorous trials to provide such proof are unlikely to occur), pre-diabetes and diabetes meet established criteria for conditions in which early detection is appropriate.”
    Quote in the paperSubstantial claim
  • Premisecitation

    The FPG and 2-h OGTT do not necessarily detect the same pre-diabetic individuals.

    “It should be noted that the two tests do not necessarily detect the same pre-diabetic individuals (9).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Gabir MM, Hanson RL, Dabelea D, Imperatore G, Roumain J, Bennett PH, Knowler WC: The 1997 American Diabetes Association and 1999 World Health Organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. Diabetes Care 23:1108–1112, 2000 source

      Not checked in the free run.

  • Premisenone given

    Effective interventions exist to reduce risk of complications of diabetes.

    “Additionally, the duration of glycemic burden is a strong predictor of adverse outcomes, and effective interventions exist to prevent progression of pre-diabetes to diabetes (see Section IV) and to reduce risk of complications of diabetes (see Section VI).”
    Quote in the paperSubstantial claim
  • May combine two claims. 123
  • Classified as probably not a substantial claim. 38
  • The quote only partly states this claim. 3

  • May combine two claims.

    Findingcitation

    The greatest predictor of A1C lowering in the 26-week CGM trial for all age-groups was frequency of sensor use, which was lower in younger age-groups.

    “Importantly, the greatest predictor of A1C lowering in this study for all age-groups was frequency of sensor use, which was lower in younger age-groups.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group: Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 359:1464–1476, 2008 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Sensor use in children, teens, and adults to age 24 years did not result in significant A1C lowering, and there was no significant difference in hypoglycemia in any group.

    “Sensor use in children, teens, and adults to age 24 years did not result in significant A1C lowering, and there was no significant difference in hypoglycemia in any group.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group: Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 359:1464–1476, 2008 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    A recent study comparing A1C to CGM data in 48 type 1 children found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r = 0.7) was significantly lower than in the ADAG trial.

    “A recent study comparing A1C to CGM data in 48 type 1 children found a highly statistically significant correlation between A1C and mean blood glucose, although the correlation (r = 0.7) was significantly lower than in the ADAG trial (44).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [44] Wilson DM, Kollman: Relationship of A1C to glucose concentrations in children with type 1 diabetes: assessments by high-frequency glucose determinations by sensors. Diabetes Care 31:381–385, 2008 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Nine-year post-DCCT follow-up of the cohort has shown that participants previously randomized to the intensive arm had a 42% reduction (P = 0.02) in cardiovascular disease outcomes and a 57% reduction (P = 0.02) in the risk of nonfatal myocardial infarction, stroke, or cardiovascular disease death compared with those previously in the standard arm.

    “However, 9-year post-DCCT follow-up of the cohort has shown that participants previously randomized to the intensive arm had a 42% reduction (P = 0.02) in CVD outcomes and a 57% reduction (P = 0.02) in the risk of nonfatal myocardial infarction (MI), stroke, or CVD death compared with those previously in the standard arm (55).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [55] Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 353:2643–2653, 2005 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    In the DCCT, there was a trend toward lower risk of cardiovascular disease events with intensive control (risk reduction 41%, 95% CI 10-68%), but the number of events was small.

    “In the DCCT, there was a trend toward lower risk of CVD events with intensive control (risk reduction 41%, 95% CI 10–68%), but the number of events was small.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    In the ADAG study, there were no significant differences among racial and ethnic groups in the regression lines between A1C and mean glucose, although there was a trend toward a difference between African/African-American and Caucasian participants' regression lines that might have been significant had more African/African-American participants been studied.

    “In the ADAG study, there were no significant differences among racial and ethnic groups in the regression lines between A1C and mean glucose, although there was a trend toward a difference between African/African-American and Caucasian participants’ regression lines that might have been significant had more African/African-American participants been studied.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    The 2-h OGTT identifies people with either IFG or IGT, and thus more pre-diabetic people at increased risk for the development of diabetes and cardiovascular disease.

    “The 2-h OGTT identifies people with either IFG or IGT, and thus, more pre-diabetic people at increased risk for the development of diabetes and CVD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The incidence of type 2 diabetes in adolescents has increased dramatically in the last decade, especially in minority populations.

    “The incidence of type 2 diabetes in adolescents has increased dramatically in the last decade, especially in minority populations (20), although the disease remains rare in the general adolescent population (21).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Dabelea D, Bell RA, D'Agostino RB Jr, Imperatore G, Johansen JM, Linder B, Liu LL, Loots B, Marcovina S, Mayer-Davis EJ, Pettitt DJ, Waitzfelder B: Incidence of diabetes in youth in the United States. JAMA 297:2716–2724, 2007

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are risk factors for future diabetes and for cardiovascular disease.

    “Both categories of pre-diabetes are risk factors for future diabetes and for cardiovascular disease (CVD) (7).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Nathan DM, Davidson MB, DeFronzo RA, Heine RJ, Henry RR, Pratley R, Zinman B: Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 30:753–759, 2007 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The FPG test is more convenient, more reproducible, less costly, and easier to administer than the 2-h OGTT.

    “As noted in the diagnosis section (Section I.B), the FPG test is more convenient, more reproducible, less costly, and easier to administer than the 2-h OGTT (4,5).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [4] Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20: 1183–1197, 1997 source

      Not checked in the free run.

    • cites [5] Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26:3160–3167, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Community screening outside a health care setting may be poorly targeted, failing to reach groups most at risk and inappropriately testing those at low risk or already diagnosed.

    “Community screening may also be poorly targeted, i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed (18,19).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] Harris R, Donahue K, Rathore SS, Frame P, Woolf SH, Lohr KN: Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 138:215–229, 2003 source

      Not checked in the free run.

    • cites [19] USPSTF: Screening for type 2 diabetes mellitus in adults: recommendations and rationale. Ann Intern Med 138:212–214, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Major clinical trials of insulin-treated patients that demonstrated benefits of intensive glycemic control on diabetes complications have included self-monitoring of blood glucose (SMBG) as part of multifactorial interventions, suggesting that SMBG is a component of effective therapy.

    “Major clinical trials of insulin-treated patients that demonstrated the benefits of intensive glycemic control on diabetes complications have included SMBG as part of multifactorial interventions, suggesting that SMBG is a component of effective therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    Small studies in selected patients with type 1 diabetes have suggested that continuous glucose monitoring (CGM) use reduces the time spent in hypo- and hyperglycemic ranges and may modestly improve glycemic control.

    “Small studies in selected patients with type 1 diabetes have suggested that CGM use reduces the time spent in hypo- and hyperglycemic ranges and may modestly improve glycemic control.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Table 8 contains the correlation between A1C levels and mean plasma glucose levels based on data from the international A1C-Derived Average Glucose (ADAG) trial utilizing frequent SMBG and continuous glucose monitoring in 507 adults (83% Caucasian) with type 1, type 2, and no diabetes.

    “Table 8 contains the correlation between A1C levels and mean plasma glucose levels based on data from the international A1C-Derived Average Glucose (ADAG) trial utilizing frequent SMBG and continuous glucose monitoring in 507 adults (83% Caucasian) with type 1, type 2, and no diabetes (49)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [49] Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34): UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:854–865, 1998 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    A1C does not provide a measure of glycemic variability or hypoglycemia.

    “In addition, A1C does not provide a measure of glycemic variability or hypoglycemia.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Point-of-care testing for A1C has been reported to result in increased intensification of therapy and improvement in glycemic control.

    “The availability of the A1C result at the time that the patient is seen (point-of-care testing) has been reported to result in increased intensification of therapy and improvement in glycemic control (40,41).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [40] Cagliero E, Levina EV, Nathan DM: Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care 22:1785–1789, 1999 source

      Not checked in the free run.

    • cites [41] Miller CD, Barnes CS, Phillips LS, Ziemer DC, Gallina DL, Cook CB, Maryman SD, El Kebbi IM: Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care 26:1158–1163, 2003 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Other measures of chronic glycemia such as fructosamine are available, but their linkage to average glucose and their prognostic significance are not as clear as is the case for A1C.

    “Other measures of chronic glycemia such as fructosamine are available, but their linkage to average glucose and their prognostic significance are not as clear as is the case for A1C.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These analyses also suggest that further lowering of A1C from 7 to 6% is associated with further reduction in the risk of microvascular complications, albeit the absolute risk reductions become much smaller.

    “These analyses also suggest that further lowering of A1C from 7 to 6% is associated with further reduction in the risk of microvascular complications, albeit the absolute risk reductions become much smaller.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Intensive glycemic control was found to increase the risk of severe hypoglycemia, most notably in the DCCT, and led to weight gain.

    “In each of these large randomized prospective clinical trials, treatment regimens that reduced average A1C to ≥7% (≥1% above the upper limits of normal) were associated with fewer long-term microvascular complications; however, intensive control was found to increase the risk of severe hypoglycemia, most notably in the DCCT, and led to weight gain (39,52).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [39] Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321:405–412, 2000 source

      Not checked in the free run.

    • cites [52] Lawson ML, Gerstein HC, Tsui E, Zinman B: Effect of intensive therapy on early macrovascular disease in young individuals with type 1 diabetes: a systematic review and meta-analysis. Diabetes Care 22 (Suppl. 2):B35–B39, 1999

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    The ACCORD glycemic control study was halted in February 2008 due to an increased rate of mortality in the intensive arm compared with the standard arm (1.41%/year vs. 1.14%/year; HR 1.22 [95% CI 1.01-1.46]), with a similar increase in cardiovascular deaths.

    “In February 2008, the glycemic control study of ACCORD was halted on the recommendation of the study's data safety monitoring board due to the finding of an increased rate of mortality in the intensive arm compared with the standard arm (1.41%/year vs. 1.14%/year; HR 1.22 [95% CI 1.01–1.46]), with a similar increase in cardiovascular deaths.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    ADVANCE participants were slightly older and of similar high CVD risk as those in ACCORD, but had an average duration of diabetes 2 years shorter, lower baseline A1C (median 7.2%), and almost no use of insulin at enrollment.

    “ADVANCE participants (who had to be at least 55 years of age with either known vascular disease or at least one other vascular risk factor) were slightly older and of similar high CVD risk as those in ACCORD. However, they had an average duration of diabetes 2 years shorter, lower baseline A1C (median 7.2%), and almost no use of insulin at enrollment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    All three trials were carried out in participants with established diabetes (mean duration 8-11 years) and either known CVD or multiple risk factors suggesting established atherosclerosis.

    “All three trials were carried out in participants with established diabetes (mean duration 8–11 years) and either known CVD or multiple risk factors suggesting the presence of established atherosclerosis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Severe hypoglycemia occurred in fewer than 3% of intensively treated ADVANCE participants for the entire study duration (median 5 years), compared with approximately 16% in ACCORD and 21% in VADT.

    “Although severe hypoglycemia was defined somewhat differently in the three trials, it appears that this occurred in fewer than 3% of intensively treated ADVANCE participants for the entire study duration (median 5 years) compared with ∼16% of intensively treated subjects in ACCORD and 21% in VADT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    In ADVANCE, median A1C levels achieved were 6.3% in the intensive arm and 7.0% in the standard arm, and maximal separation between the arms took several years to achieve.

    “The median A1C levels achieved in the intensive and standard arms were 6.3 and 7.0%, respectively, and maximal separation between the arms took several years to achieve.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    ADVANCE participants on average appeared to have earlier or less advanced diabetes, with shorter duration by 2-3 years and lower A1C at entry despite very little use of insulin at baseline.

    “ADVANCE participants on average appeared to have earlier or less advanced diabetes, with shorter duration by 2–3 years and lower A1C at entry despite very little use of insulin at baseline.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In ADVANCE, intensive glycemic control significantly reduced the primary endpoint (HR 0.90 [95% CI 0.82-0.98]; P = 0.01), due to a significant reduction in the microvascular outcome (0.86 [0.77-0.97], P = 0.01), primarily macroalbuminuria, with no significant reduction in the macrovascular outcome (0.94 [0.84-1.06]; P = 0.32).

    “Intensive glycemic control significantly reduced the primary endpoint (HR 0.90 [95% CI 0.82–0.98]; P = 0.01), although this was due to a significant reduction in the microvascular outcome (0.86 [0.77–0.97], P = 0.01), primarily development of macroalbuminuria, with no significant reduction in the macrovascular outcome (0.94 [0.84–1.06]; P = 0.32).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, Marre M, Cooper M, Glasziou P, Grobbee D, Hamet P, Harrap S, Heller S, Liu L, Mancia G, Mogensen CE, Pan C, Poulter N, Rodgers A, Williams B, Bompoint S, De Galan BE, Joshi R, Travert F: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358:2560–2572, 2008

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    ACCORD prespecified subset analyses showed that participants with no previous CVD event and those with baseline A1C <8% had a statistically significant reduction in the primary CVD outcome.

    “Prespecified subset analyses showed that participants with no previous CVD event and those who had a baseline A1C <8% had a statistically significant reduction in the primary CVD outcome.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    By design of ACCORD, randomization to the intensive arm was associated with or led to many downstream effects, such as higher rates of severe hypoglycemia, more frequent use of insulin, TZDs, other drugs, and drug combinations, and greater weight gain.

    “By design of the trial, randomization to the intensive arm was associated with or led to many downstream effects, such as higher rates of severe hypoglycemia; more frequent use of insulin, TZDs, other drugs, and drug combinations; and greater weight gain.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The ACCORD primary outcome (MI, stroke, or cardiovascular death) was lower in the intensive glycemic control group due to a reduction in nonfatal MI, but this finding was not statistically significant when the study was terminated (HR 0.90 [95% CI 0.78-1.04]; P = 0.16).

    “The primary outcome of ACCORD (MI, stroke, or cardiovascular death) was lower in the intensive glycemic control group due to a reduction in nonfatal MI, although this finding was not statistically significant when the study was terminated (HR 0.90 [95% CI 0.78–1.04]; P = 0.16) (56).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [56] Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB, Cushman WC, Genuth S, Ismail-Beigi F, Grimm RH Jr, Probstfield JL, Simons-Morton DG, Friedewald WT: Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 358:2545–2559, 2008 source

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    VADT post hoc subgroup analyses suggested that duration of diabetes interacted with randomization such that participants with duration less than about 12 years appeared to have a CVD benefit of intensive glycemic control, while those with longer duration had a neutral or even adverse effect.

    “Post hoc subgroup analyses suggested that duration of diabetes interacted with randomization such that participants with duration of diabetes less than about 12 years appeared to have a CVD benefit of intensive glycemic control while those with longer duration of disease before study entry had a neutral or even adverse effect of intensive glycemic control.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    The UKPDS trial of type 2 diabetes observed a 16% reduction in cardiovascular complications (combined fatal or nonfatal MI and sudden death) in the intensive glycemic control arm, but this difference was not statistically significant (P = 0.052), and there was no suggestion of benefit on other CVD outcomes such as stroke.

    “The UKPDS trial of type 2 diabetes observed a 16% reduction in cardiovascular complications (combined fatal or nonfatal MI and sudden death) in the intensive glycemic control arm, although this difference was not statistically significant (P = 0.052), and there was no suggestion of benefit on other CVD outcomes such as stroke.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    In ACCORD, from a baseline median A1C of 8.1%, the intensive arm reached a median A1C of 6.4% within 12 months, while the standard group reached a median A1C of 7.5%.

    “From a baseline median A1C of 8.1%, the intensive arm reached a median A1C of 6.4% within 12 months of randomization, while the standard group reached a median A1C of 7.5%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    A1C was lowered less and more gradually in ADVANCE, and there was no significant weight gain with intensive glycemic therapy.

    “A1C was also lowered less and more gradually in the ADVANCE trial, and there was no significant weight gain with intensive glycemic therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    VADT exploratory analyses suggested that severe hypoglycemia within the past 90 days was a strong predictor of the primary outcome and of CVD mortality.

    “Other exploratory analyses suggested that severe hypoglycemia within the past 90 days was a strong predictor of the primary outcome and of CVD mortality (58).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Duckworth W: VADT results. Presented at the 68th Annual Meeting of the American Diabetes Association, 6–10 June 2008, at the Moscone Convention Center, San Francisco, CA

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    The ADVANCE study achieved a median A1C in its intensive arm similar to that in ACCORD, with no increased mortality hazard.

    “The ADVANCE study achieved a median A1C in its intensive arm similar to that in the ACCORD study, with no increased mortality hazard.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    In VADT, there were more CVD deaths in the intensive arm than in the standard arm (40 vs. 33; sudden deaths 11 vs. 4), but the difference was not statistically significant.

    “There were more CVD deaths in the intensive arm than in the standard arm (40 vs. 33; sudden deaths 11 vs. 4), but the difference was not statistically significant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Such factors may be associated statistically with the higher mortality rate in the ACCORD intensive arm but may not be causative.

    “Such factors may be associated statistically with the higher mortality rate in the intensive arm but may not be causative.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premiseown data

    In an epidemiologic analysis of the UKPDS cohort, for every percentage point lower median on-study A1C there was a statistically significant 18% reduction in CVD events, with no glycemic threshold.

    “In an epidemiologic analysis of the study cohort, a continuous association was observed, such that for every percentage point lower median on-study A1C (e.g., 8 to 7%) there was a statistically significant 18% reduction in CVD events, again with no glycemic threshold.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premiseown data

    The ACCORD intensive glycemic control group had more use of insulin in combination with multiple oral agents, significantly more weight gain, and more episodes of severe hypoglycemia than the standard group.

    “The intensive glycemic control group had more use of insulin in combination with multiple oral agents, significantly more weight gain, and more episodes of severe hypoglycemia than the standard group.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In ADVANCE, there was no difference in overall or cardiovascular mortality between the intensive and standard glycemic control arms.

    “There was no difference in overall or cardiovascular mortality between the intensive and the standard glycemic control arms (57).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [57] Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, Marre M, Cooper M, Glasziou P, Grobbee D, Hamet P, Harrap S, Heller S, Liu L, Mancia G, Mogensen CE, Pan C, Poulter N, Rodgers A, Williams B, Bompoint S, De Galan BE, Joshi R, Travert F: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358:2560–2572, 2008

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.

    “For individuals with diabetes, the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution higher at A1C levels closer to 7%.

    “It is clear that postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C levels that are closer to 7%.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Elevated postchallenge (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of FPG in some epidemiological studies.

    “Elevated postchallenge (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of FPG in some epidemiological studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the Food and Drug Administration.

    “Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the Food and Drug Administration (FDA).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    The recommendations for glycemic goals for nonpregnant adults are based on those for A1C, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7%.

    “The recommendations are based on those for A1C, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    It may be that glycemic control plays a greater role before macrovascular disease is well developed and minimal or no role when it is advanced.

    “As is the case with microvascular complications, it may be that glycemic control plays a greater role before macrovascular disease is well developed and minimal or no role when it is advanced.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Outcome studies have shown A1C to be the primary predictor of complications, and landmark glycemic control trials such as DCCT and UKPDS relied overwhelmingly on preprandial SMBG.

    “However, outcome studies have clearly shown A1C to be the primary predictor of complications, and landmark glycemic control trials such as the DCCT and UKPDS relied overwhelmingly on preprandial SMBG.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Clinical trials and outcome studies of MNT have reported decreases in A1C at 3-6 months ranging from 0.25 to 2.9%, with higher reductions seen in type 2 diabetes of shorter duration.

    “Clinical trials/outcome studies of MNT have reported decreases in A1C at 3–6 months ranging from 0.25 to 2.9% with higher reductions seen in type 2 diabetes of shorter duration.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Several randomized controlled trials found that subjects on low-carbohydrate diets (<130 g/day of carbohydrate) lost more weight at 6 months than subjects on low-fat diets, but at 1 year the difference in weight loss was not significant and weight loss was modest with both diets.

    “several randomized controlled trials found that subjects on low-carbohydrate diets (<130 g/day of carbohydrate) lost more weight at 6 months than subjects on low-fat diets (88,89); however, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant, and weight loss was modest with both diets.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [88] Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman JS, Klein S: A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 348:2082–2090, 2003 source

      Not checked in the free run.

    • cites [89] Stern L, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams M, Gracely EJ, Samaha FF: The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med 140:778–785, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Meta-analyses of studies in nondiabetic, free-living subjects report that MNT reduces LDL cholesterol by 15-25 mg/dl or can lower LDL cholesterol by up to 16%, while clinical trials support a role for lifestyle modification in treating hypertension.

    “Meta-analyses of studies in nondiabetic, free-living subjects report that MNT reduces LDL cholesterol by 15–25 mg/dl (77) or can lower LDL cholesterol by up to 16% (78), while clinical trials support a role for lifestyle modification in treating hypertension (78,79).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [77] Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM: Effects of the National Cholesterol Education Program's Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr 69:632–646, 1999 source

      Not checked in the free run.

    • cites [78] Van Horn L, McCoin M, Kris-Etherton PM, Burke F, Carson JA, Champagne CM, Karmally W, Sikand G: The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 108:287–331, 2008 source

      Not checked in the free run.

    • cites [79] Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N: A clinical trial of the effects of dietary patterns on blood pressure: DASH Collaborative Research Group. N Engl J Med 336:1117–1124, 1997 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The multifactorial intensive lifestyle intervention employed in the DPP led to weight loss averaging 7% at 6 months and maintenance of 5% weight loss at 3 years, associated with a 58% reduction in incidence of type 2 diabetes.

    “The multifactorial intensive lifestyle intervention employed in the DPP, which included reduced intake of fat and calories, led to weight loss averaging 7% at 6 months and maintenance of 5% weight loss at 3 years, associated with a 58% reduction in incidence of type 2 diabetes (10).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403, 2002 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Longer-term studies (52 weeks) showed mixed effects on A1C in adults with type 2 diabetes, and results were confounded by pharmacologic weight loss therapy.

    “longer-term studies (52 weeks) showed mixed effects on A1C in adults with type 2 diabetes (82–85), and results were confounded by pharmacologic weight loss therapy.”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [82] Norris SL, Zhang X, Avenell A, Gregg E, Schmid CH, Kim C, Lau J: Efficacy of pharmacotherapy for weight loss in adults with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med 164:1395–1404, 2004 source

      Not checked in the free run.

    • cites [83] Wolf AM, Conaway MR, Crowther JQ, Hazen KY, Nadler L, Oneida B, Bovbjerg VE: Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care 27:1570–1576, 2004 source

      Not checked in the free run.

    • cites [84] Manning RM, Jung RT, Leese GP, Newton RW: The comparison of four weight reduction strategies aimed at overweight patients with diabetes mellitus: four-year follow-up. Diabet Med 15:497–502, 1998 source

      Not checked in the free run.

    • cites [85] Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Bluher M, Stumvoll M, Stampfer MJ: Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 359:229–241, 2008 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    The FDA has approved five nonnutritive sweeteners for use in the U.S., and all underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy.

    “The FDA has approved five nonnutritive sweeteners for use in the U.S.: acesulfame potassium, aspartame, neotame, saccharin, and sucralose. Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    There is a lack of evidence on the effects of specific fatty acids on people with diabetes, so the recommended goals are consistent with those for individuals with CVD.

    “There is a lack of evidence on the effects of specific fatty acids on people with diabetes, so the recommended goals are consistent with those for individuals with CVD (78,95).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [78] Van Horn L, McCoin M, Kris-Etherton PM, Burke F, Carson JA, Champagne CM, Karmally W, Sikand G: The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 108:287–331, 2008 source

      Not checked in the free run.

    • cites [95] Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 25:148–198, 2002 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Resolution rates of diabetes after bariatric surgery are lowest with procedures that only constrict the stomach and higher with those that bypass portions of the small intestine.

    “Resolution rates are lowest with procedures that only constrict the stomach and higher with those that bypass portions of the small intestine.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    In the trial comparing adjustable gastric banding to medical and lifestyle therapy, the medically treated group lost only 1.7% of body weight, suggesting that their therapy was not optimal.

    “The latter group lost only 1.7% of body weight, suggesting that their therapy was not optimal.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The trial comparing adjustable gastric banding to medical and lifestyle therapy had 60 subjects, and only 13 had a BMI under 35 kg/m2, making it difficult to generalize these results widely to diabetic patients who are less severely obese or with longer duration of diabetes.

    “Overall, the trial had 60 subjects, and only 13 had a BMI under 35 kg/m2, making it difficult to generalize these results widely to diabetic patients who are less severely obese or with longer duration of diabetes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    The use of sugar alcohols appears to be safe; however, they may cause diarrhea, especially in children.

    “The use of sugar alcohols appears to be safe; however, they may cause diarrhea, especially in children.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets.

    “A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets (91).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS Jr, Brehm BJ, Bucher HC: Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 166:285–293, 2006 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A meta-analysis of studies of bariatric surgery reported that 78% of individuals with type 2 diabetes had complete resolution of diabetes, and resolution rates were sustained in studies with follow-up exceeding 2 years.

    “A meta-analysis of studies of bariatric surgery reported that 78% of individuals with type 2 diabetes had complete “resolution” of diabetes (normalization of blood glucose levels in the absence of medications), and that the resolution rates were sustained in studies that had follow-up exceeding 2 years (96).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [96] Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I: Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. In Press

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals.

    “Although brain fuel needs can be met on lower carbohydrate diets, long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals that are important in dietary palatability (92).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [92] Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, D.C., National Academies Press, 2002

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Rates of morbidity and mortality directly related to bariatric surgery have been reduced considerably in recent years, with 30-day mortality rates now 0.28%, similar to those of laparoscopic cholecystectomy.

    “Rates of morbidity and mortality directly related to the surgery have been reduced considerably in recent years, with 30-day mortality rates now 0.28%, similar to those of laparoscopic cholecystectomy (98).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [98] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I: Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 142:621–632, 2007 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisenone given

    Ongoing DSME helps people with diabetes maintain effective self-management as their diabetes presents new challenges and treatment advances become available.

    “Ongoing DSME also helps people with diabetes maintain effective self-management as their diabetes presents new challenges and treatment advances become available.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Since the 1990s, there has been a shift from a didactic approach in DSME to a skill-based approach that focuses on helping those with diabetes make informed self-management choices.

    “Since the 1990s, there has been a shift from a didactic approach, with DSME focusing on providing information, to a skill-based approach that focuses on helping those with diabetes make informed self-management choices.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Better outcomes were reported for DSME interventions that were longer and included follow-up support, that were tailored to individual needs and preferences, and that addressed psychosocial issues.

    “Better outcomes were reported for DSME interventions that were longer and included follow-up support (101), that were tailored to individual needs and preferences (100), and that addressed psychosocial issues (100,101,105).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [101] Norris SL, Engelgau MM, Narayan KM: Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 24:561–587, 2001 source

      Not checked in the free run.

    • cites [100] Piette JD, Glasgow RE: Sttategies for improving behavioral and health outcomes among people with diabetes: self managemnt education. In Evidence-Based Diabetes Care. Gerstein HC, Hayes RB, Eds. Ontario, Canada, BC Decker, 2000

      Not checked in the free run.

    • cites [105] Ellis SE, Speroff T, Dittus RS, Brown A, Pichert JW, Elasy TA: Diabetes patient education: a meta-analysis and meta-regression. Patient Educ Couns 52:97–105, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    DSME helps patients optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner.

    “DSME helps patients optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner (108).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [108] Mulcahy K, Maryniuk M, Peeples M, Peyrot M, Tomky D, Weaver T, Yarborough P: Diabetes self-management education core outcomes measures. Diabetes Educ 29:768-84:787, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    Longer-term concerns of bariatric surgery include vitamin and mineral deficiencies, osteoporosis, and rare but often severe hypoglycemia from insulin hypersecretion.

    “Longer-term concerns include vitamin and mineral deficiencies, osteoporosis, and rare but often severe hypoglycemia from insulin hypersecretion.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Several studies have found that DSME is associated with improved diabetes knowledge and improved self-care behavior, improved clinical outcomes such as lower A1C, lower self-reported weight, and improved quality of life.

    “Several studies have found that DSME is associated with improved diabetes knowledge and improved self-care behavior (101), improved clinical outcomes such as lower A1C (102,103,105,106,110), lower self-reported weight (101), and improved quality of life (104).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [101] Norris SL, Engelgau MM, Narayan KM: Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 24:561–587, 2001 source

      Not checked in the free run.

    • cites [102] Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 25:1159–1171, 2002 source

      Not checked in the free run.

    • cites [104] Steed L, Cooke D, Newman S: A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus. Patient Educ Couns 51:5–15, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    DSME is an essential element of diabetes care, and National Standards for DSME are based on evidence for its benefits.

    “DSME is an essential element of diabetes care (100–106), and National Standards for DSME (107) are based on evidence for its benefits.”
    Quote in the paperSubstantial claim0 of 7 sources checked
    • cites [100] Piette JD, Glasgow RE: Sttategies for improving behavioral and health outcomes among people with diabetes: self managemnt education. In Evidence-Based Diabetes Care. Gerstein HC, Hayes RB, Eds. Ontario, Canada, BC Decker, 2000

      Not checked in the free run.

    • cites [101] Norris SL, Engelgau MM, Narayan KM: Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 24:561–587, 2001 source

      Not checked in the free run.

    • cites [102] Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 25:1159–1171, 2002 source

      Not checked in the free run.

    • cites [103] Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL: Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ 29:488–501, 2003 source

      Not checked in the free run.

    • cites [104] Steed L, Cooke D, Newman S: A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus. Patient Educ Couns 51:5–15, 2003 source

      Not checked in the free run.

    • cites [105] Ellis SE, Speroff T, Dittus RS, Brown A, Pichert JW, Elasy TA: Diabetes patient education: a meta-analysis and meta-regression. Patient Educ Couns 52:97–105, 2004 source

      Not checked in the free run.

    • cites [106] Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH: Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 164:1641–1649, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Both individual and group approaches to DSME have been found effective.

    “Both individual and group approaches have been found effective ((111,112).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [111] Rickheim PL, Weaver TW, Flader JL, Kendall DM: Assessment of group versus individual diabetes education: a randomized study. Diabetes Care 25:269–274, 2002 source

      Not checked in the free run.

    • cites [112] Trento M, Passera P, Borgo E, Tomalino M, Bajardi M, Cavallo F, Porta M: A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care 27:670–675, 2004 source

      Not checked in the free run.

  • The quote only partly states this claim.

    Premisecitation

    Regular exercise reduces cardiovascular risk factors.

    “Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well being.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [114] Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C: Physical activity/exercise and type 2 diabetes. Diabetes Care 27:2518–2539, 2004 source

      Not checked in the free run.

    • cites [115] Wasserman DH, Zinman B: Exercise in individuals with IDDM. Diabetes Care 17:924–937, 1994 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the meta-analysis of exercise interventions on glycemic control, the mean number of sessions per week was 3.4 and the mean session duration was 49 min.

    “The studies included in the meta-analysis of effects of exercise interventions on glycemic control (116) had a mean number of sessions per week of 3.4, with a mean of 49 min per session.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [116] Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ: Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 286:1218–1227, 2001 source

      Not checked in the free run.

  • The quote only partly states this claim.

    Premisecitation

    Regular exercise contributes to weight loss.

    “Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well being.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [114] Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C: Physical activity/exercise and type 2 diabetes. Diabetes Care 27:2518–2539, 2004 source

      Not checked in the free run.

    • cites [115] Wasserman DH, Zinman B: Exercise in individuals with IDDM. Diabetes Care 17:924–937, 1994 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness.

    “Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness (117).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [117] Boulé NG, Kenny GP, Haddad E, Wells GA, Sigal RJ: Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in type 2 diabetes mellitus. Diabetologia 46:1071–1081, 2003 source

      Not checked in the free run.

  • The quote only partly states this claim.

    Premisecitation

    Regular exercise improves well being.

    “Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well being.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [114] Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C: Physical activity/exercise and type 2 diabetes. Diabetes Care 27:2518–2539, 2004 source

      Not checked in the free run.

    • cites [115] Wasserman DH, Zinman B: Exercise in individuals with IDDM. Diabetes Care 17:924–937, 1994 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Issues known to impact self-management and health outcomes include attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources, and psychiatric history.

    “Issues known to impact self-management and health outcomes include but are not limited to attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional) (136), and psychiatric history (137,140,141).”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [136] Surwit RS, Schneider MS, Feinglos MN: Stress and diabetes mellitus. Diabetes Care 15:1413–1422, 1992 source

      Not checked in the free run.

    • cites [137] Young-Hyman D: Psycosocial factors affecting adherence, quality of life, and well-being: Helping patients cope. In Medical Management of Type 1 Diabetes. 4th ed. Bode B, Ed. Alexandria, VA, American Diabetes Association, 2004, p. 162–182

      Not checked in the free run.

    • cites [140] McCulloch DK, Glasgow RE, Hampson SE, Wagner E: A systematic approach to diabetes management in the post-DCCT era. Diabetes Care 17:765–769, 1994 source

      Not checked in the free run.

    • cites [141] Rubin RR, Peyrot M: Psychological issues and treatments for people with diabetes. J ClinPsychol 57:457–478, 2001 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The deficient counter-regulatory hormone release and autonomic responses in hypoglycemia unawareness are both risk factors for, and caused by, hypoglycemia.

    “The deficient counter-regulatory hormone release and autonomic responses in this syndrome are both risk factors for, and caused by, hypoglycemia.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [146] Cryer PE: Hypoglycaemia: the limiting factor in the glycaemic management of type I and type II diabetes. Diabetologia 45:937–948, 2002 source

      Not checked in the free run.

    • cites [148] Cryer PE: Diverse causes of hypoglycemia-associated autonomic failure in diabetes. N Engl J Med 350:2272–2279, 2004 source

      Not checked in the free run.

    • cites [149] Cryer PE, Davis SN, Shamoon H: Hypoglycemia in diabetes. Diabetes Care 26:1902–1912, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis or nonketotic hyperosmolar state.

    “The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis (DKA) or nonketotic hyperosmolar state, life-threatening conditions that require immediate medical care to prevent complications and death (145).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [145] American Diabetes Association: Hyperglycemic crises in diabetes. Diabetes Care 27 (Suppl. 1):S94–S102, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    People with diabetes may be at increased risk of the bacteremic form of pneumococcal infection and have been reported to have a high risk of nosocomial bacteremia, which has a mortality rate as high as 50%.

    “People with diabetes may be at increased risk of the bacteremic form of pneumococcal infection and have been reported to have a high risk of nosocomial bacteremia, which has a mortality rate as high as 50% (150).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [150] Smith SA, Poland GA: Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 23:95–108, 2000 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Other studies have shown no specific advantage to ACE inhibitors as initial treatment of hypertension in the general hypertensive population, but rather an advantage on cardiovascular outcomes of initial therapy with low-dose thiazide diuretics.

    “However, a variety of other studies have shown no specific advantage to ACE inhibitors as initial treatment of hypertension in the general hypertensive population, but rather an advantage on cardiovascular outcomes of initial therapy with low-dose thiazide diuretics (160,172,173).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [160] Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560–2572, 2003 source

      Not checked in the free run.

    • cites [172] Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 288:2981–2997, 2002 source

      Not checked in the free run.

    • cites [173] Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH, Weiss NS: Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 289:2534–2544, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Nicotinic acid has been shown to reduce CVD outcomes, although the study was done in a nondiabetic cohort.

    “Nicotinic acid has been shown to reduce CVD outcomes (194), although the study was done in a nondiabetic cohort.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [194] Canner PL, Berge KG, Wenger NK, Stamler J, Friedman L, Prineas RJ, Friedewald W: Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol 8:1245–1255, 1986 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Chronic diuretic use during pregnancy has been associated with restricted maternal plasma volume, which might reduce uteroplacental perfusion.

    “Chronic diuretic use during pregnancy has been associated with restricted maternal plasma volume, which might reduce uteroplacental perfusion (184).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [184] Sibai BM: Treatment of hypertension in pregnant women. N Engl J Med 335:257–265, 1996 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Gemfibrozil has been shown to decrease rates of CVD events in subjects without diabetes and in the diabetic subgroup in one of the larger trials.

    “Gemfibrozil has been shown to decrease rates of CVD events in subjects without diabetes (195,196) and in the diabetic subgroup in one of the larger trials (195).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [195] Rubins HB, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas FH, Linares E, Schaefer EJ, Schectman G, Wilt TJ, Wittes J: Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol: Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med 341:410–418, 1999 source

      Not checked in the free run.

    • cites [196] Frick MH, Elo O, Haapa K, Heinonen OP, Heinsalmi P, Helo P, Huttunen JK, Kaitaniemi P, Koskinen P, Manninen V: Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia: safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med 317:1237–1245, 1987 source

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    Reduction in hard CVD outcomes (CHD death and nonfatal MI) can be more clearly seen in diabetic subjects with high baseline CVD risk, but overall the benefits of statin therapy in people with diabetes at moderate or high risk for CVD are convincing.

    “As shown in Table 10, and similar to findings in nondiabetic subjects, reduction in “hard” CVD outcomes (CHD death and nonfatal MI) can be more clearly seen in diabetic subjects with high baseline CVD risk (known CVD and/or very high LDL cholesterol levels), but overall the benefits of statin therapy in people with diabetes at moderate or high risk for CVD are convincing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The risk of rhabdomyolysis is higher with higher doses of statins and with renal insufficiency and seems lower when statins are combined with fenofibrate than gemfibrozil.

    “The risk of rhabdomyolysis is higher with higher doses of statins and with renal insufficiency and seems to be lower when statins are combined with fenofibrate than gemfibrozil (207).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [207] Jones PH, and Davidson MH Reporting rate of rhabdomyolysis with fenofibrate + statin versus gemfibrozil + any statin. Am J Cardiol 95:120–122, 2005 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    At modest doses (750-2,000 mg/day), niacin significantly improves LDL cholesterol, HDL cholesterol, and triglyceride levels with only modest changes in glucose generally amenable to adjustment of diabetes therapy.

    “It can significantly increase blood glucose at high doses, but recent studies demonstrate that at modest doses (750–2,000 mg/day), significant improvements in LDL cholesterol, HDL cholesterol, and triglyceride levels are accompanied by only modest changes in glucose that are generally amenable to adjustment of diabetes therapy (205,206).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [205] Elam MB, Hunninghake DB, Davis KB, Garg R, Johnson C, Egan D, Kostis JB, Sheps DS, Brinton EA: Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: a randomized trial: Arterial Disease Multiple Intervention Trial. JAMA 284:1263–1270, 2000 source

      Not checked in the free run.

    • cites [206] Grundy SM, Vega GL, McGovern ME, Tulloch BR, Kendall DM, Fitz-Patrick D, Ganda OP, Rosenson RS, Buse JB, Robertson DD, Sheehan JP: Efficacy, safety, and tolerability of once-daily niacin for the treatment of dyslipidemia associated with type 2 diabetes: results of the assessment of diabetes control and evaluation of the efficacy of niaspan trial. Arch Intern Med 162:1568–1576, 2002 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In individual patients, LDL cholesterol lowering with statins is highly variable, and this variable response is poorly understood.

    “In individual patients, LDL cholesterol lowering with statins is highly variable, and this variable response is poorly understood (204).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [204] Chasman DI, Posada D, Subrahmanyan L, Cook NR, Stanton VP Jr, Ridker PM: Pharmacogenetic study of statin therapy and cholesterol reduction. JAMA 291:2821–2827, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Clear benefit exists for ACE inhibitor and ARB therapy in patients with nephropathy or hypertension, but benefits in patients with CVD in the absence of these conditions is less clear, especially when LDL cholesterol is concomitantly controlled.

    “While clear benefit exists for ACE inhibitor and ARB therapy in patients with nephropathy or hypertension, the benefits in patients with CVD in the absence of these conditions is less clear, especially when LDL cholesterol is concomitantly controlled (224,225)”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [224] Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J, Pfeffer MA, Rice MM, Rosenberg YD, Rouleau JL: Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 351:2058–2068, 2004 source

      Not checked in the free run.

    • cites [225] Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 372:1174–1183, 2008 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Intensive diabetes management with the goal of achieving near normoglycemia delays the onset of microalbuminuria and the progression of micro- to macroalbuminuria in patients with type 1 and type 2 diabetes.

    “Intensive diabetes management with the goal of achieving near normoglycemia has been shown in large prospective randomized studies to delay the onset of microalbuminuria and the progression of micro- to macroalbuminuria in patients with type 1 (230,231) and type 2 (49,50) diabetes.”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [230] Reichard P, Nilsson BY, Rosenqvist U: The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 329:304–309, 1993 source

      Not checked in the free run.

    • cites [231] Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial: the Diabetes Control and Complications (DCCT) Research Group. Kidney Int 47:1703–1720, 1995 source

      Not checked in the free run.

    • cites [49] Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34): UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:854–865, 1998 source

      Not checked in the free run.

    • cites [50] Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33): UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:837–853, 1998 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In addition to duration of diabetes, chronic hyperglycemia, presence of nephropathy, and hypertension increase the risk of, or are associated with, retinopathy.

    “In addition to duration of diabetes, other factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia (255), the presence of nephropathy (256), and hypertension (257).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [255] Klein R: Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 18:258–268, 1995 source

      Not checked in the free run.

    • cites [256] Estacio RO, McFarling E, Biggerstaff S, Jeffers BW, Johnson D, Schrier RW: Overt albuminuria predicts diabetic retinopathy in Hispanics with NIDDM. Am J Kidney Dis 31:947–953, 1998 source

      Not checked in the free run.

    • cites [257] Leske MC, Wu SY, Hennis A, Hyman L, Nemesure B, Yang L, Schachat AP: Hyperglycemia, blood pressure, and the 9-year incidence of diabetic retinopathy: the Barbados Eye Studies. Ophthalmology 112:799–805, 2005 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Screening for microalbuminuria can be performed by measurement of the albumin-to-creatinine ratio in a random spot collection; 24-h or timed collections are more burdensome and add little to prediction or accuracy.

    “Screening for microalbuminuria can be performed by measurement of the albumin-to-creatinine ratio in a random spot collection (preferred method); 24-h or timed collections are more burdensome and add little to prediction or accuracy (247,248).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [247] Eknoyan G, Hostetter T, Bakris GL, Hebert L, Levey AS, Parving HH, Steffes MW, Toto R: Proteinuria and other markers of chronic kidney disease: a position statement of the national kidney foundation (NKF) and the national institute of diabetes and digestive and kidney diseases (NIDDK). Am J Kidney Dis 42:617–622, 2003 source

      Not checked in the free run.

    • cites [248] Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G: National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 139:137–147, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Pregnancy in type 1 diabetic patients may aggravate retinopathy; laser photocoagulation surgery can minimize this risk.

    “Several case series and a controlled prospective study suggest that pregnancy in type 1 diabetic patients may aggravate retinopathy (258,259); laser photocoagulation surgery can minimize this risk (259).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [258] Fong DS, Aiello LP, Ferris FL III, Klein R: Diabetic retinopathy. Diabetes Care 27:2540–2553, 2004 source

      Not checked in the free run.

    • cites [259] DCCT: Effect of pregnancy on microvascular complications in the diabetes control and complications trial: The Diabetes Control and Complications Trial Research Group. Diabetes Care 23:1084–1091, 2000 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The ETDRS verified the benefits of panretinal photocoagulation for high-risk PDR, but not for mild or moderate NPDR.

    “The ETDRS also verified the benefits of panretinal photocoagulation for high-risk PDR, but not for mild or moderate NPDR.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [261] Photocoagulation for diabetic macular edema: Early Treatment Diabetic Retinopathy Study report number 1: Early Treatment Diabetic Retinopathy Study Research Group. Arch Ophthalmol 103:1796–1806, 1985 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Consultation with a nephrologist when stage 4 CKD develops reduces cost, improves quality of care, and keeps people off dialysis longer.

    “Consultation with a nephrologist when stage 4 CKD develops has been found to reduce cost, improve quality of care, and keep people off dialysis longer (253,254).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [253] Levinsky NG: Specialist evaluation in chronic kidney disease: too little, too late. Ann Intern Med 137:542–543, 2002 source

      Not checked in the free run.

    • cites [254] American Diabetes Association: Nephropathy in diabetes (Position Statement). Diabetes Care 27 (Suppl. 1):S79–S83, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    Laser photocoagulation surgery in both trials was beneficial in reducing the risk of further vision loss, but generally not beneficial in reversing already diminished acuity.

    “Laser photocoagulation surgery in both trials was beneficial in reducing the risk of further vision loss, but generally not beneficial in reversing already diminished acuity.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [260] The Diabetic Retinopathy Study (DRS) Research Group: Preliminary report on the effects of photocoagulation therapy: DRS Report #1. Am J Ophthalmol 81:383–396, 1976 source

      Not checked in the free run.

    • cites [261] Photocoagulation for diabetic macular edema: Early Treatment Diabetic Retinopathy Study report number 1: Early Treatment Diabetic Retinopathy Study Research Group. Arch Ophthalmol 103:1796–1806, 1985 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Patients with type 2 diabetes generally have had years of undiagnosed diabetes and have a significant risk of prevalent diabetic retinopathy at time of diabetes diagnosis.

    “Patients with type 2 diabetes, who generally have had years of undiagnosed diabetes (263) and who have a significant risk of prevalent diabetic retinopathy at time of diabetes diagnosis, should have an initial dilated and comprehensive eye examination soon after diagnosis.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [263] Harris MI, Klein R, Welborn TA, Knuiman MW: Onset of NIDDM occurs at least 4–7 yr before clinical diagnosis. Diabetes Care 15:815–819, 1992 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Loss of 10-g monofilament perception and reduced vibration perception predict foot ulcers.

    “Loss of 10-g monofilament perception and reduced vibration perception predict foot ulcers (270).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [270] Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, Malik RA, Maser RE, Sosenko JM, Ziegler D: Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 28:956–962, 2005 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The AHA categorizes type 1 children in the highest tier for cardiovascular risk and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cholesterol levels.

    “the AHA categorizes type 1 children in the highest tier for cardiovascular risk and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cholesterol levels (285,286).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [285] Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, Parekh RS, Steinberger J: Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy o source

      Not checked in the free run.

    • cites [286] McCrindle BW, Urbina EM, Dennison BA, Jacobson MS, Steinberger J, Rocchini AP, Hayman LL, Daniels SR: Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation 115:1948–1967, 2007 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Data from randomized clinical trials in children as young as 7 months of age indicate that a Step 2 AHA diet is safe and does not interfere with normal growth and development.

    “Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and development (287,288).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [287] Salo P, Viikari J, Hamalainen M, Lapinleimu H, Routi T, Ronnemaa T, Seppanen R, Jokinen E, Valimaki I, Simell O: Serum cholesterol ester fatty acids in 7- and 13-month-old children in a prospective randomized trial of a low-saturated fat, low-cholesterol diet: the STRIP baby project: Special Turku coronary Risk factor Intervention Project for children. Acta Paediatr 88:505–512, 1999 source

      Not checked in the free run.

    • cites [288] Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol: the Dietary Intervention Study in Children (DISC): the Writing Group for the DISC Collaborative Research Group. JAMA 273:1429–1435, 1995 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Neither long-term safety nor cardiovascular outcome efficacy has been established for statins in children.

    “Neither long-term safety nor cardiovascular outcome efficacy has been established for children.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The A1C level achieved in the "intensive" adolescent cohort of the DCCT group was >1% higher than that achieved by adult DCCT subjects and above current ADA recommendations for patients in general.

    “The A1C level achieved in the “intensive” adolescent cohort of the DCCT group was >1% higher than that achieved by adult DCCT subjects and above current ADA recommendations for patients in general.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites DCCT

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Recent studies have shown statins have short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels, improving endothelial function, and causing regression of carotid intimal thickening in children.

    “recent studies have shown short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels, improving endothelial function, and causing regression of carotid intimal thickening (289–291).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [289] McCrindle BW, Ose L, Marais AD: Efficacy and safety of atorvastatin in children and adolescents with familial hypercholesterolemia or severe hyperlipidemia: a multicenter, randomized, placebo-controlled trial. J Pediatr 143:74–80, 2003 source

      Not checked in the free run.

    • cites [290] de Jongh S, Lilien MR, op't RJ, Stroes ES, Bakker HD, Kastelein JJ: Early statin therapy restores endothelial function in children with familial hypercholesterolemia. J Am Coll Cardiol 40:2117–2121, 2002 source

      Not checked in the free run.

    • cites [291] Wiegman A, Hutten BA, de Groot E, Rodenburg J, Bakker HD, Buller HR, Sijbrands EJ, Kastelein JJ: Efficacy and safety of statin therapy in children with familial hypercholesterolemia: a randomized controlled trial. JAMA 292:331–337, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with type 1 diabetes (1-16% of individuals compared with 0.3-1% in the general population).

    “Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with type 1 diabetes (1–16% of individuals compared with 0.3–1% in the general population) (292,293).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [292] Holmes GK: Screening for coeliac disease in type 1 diabetes. Arch Dis Child 87:495–498, 2002 source

      Not checked in the free run.

    • cites [293] Rewers M, Liu E, Simmons J, Redondo MJ, Hoffenberg EJ: Celiac disease associated with type 1 diabetes mellitus. Endocrinol Metab Clin North Am 33:197–214, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17-30% of patients with type 1 diabetes.

    “Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17–30% of patients with type 1 diabetes (294).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [294] Roldan MB, Alonso M, Barrio R: Thyroid autoimmunity in children and adolescents with type 1 diabetes mellitus. Diabetes Nutr Metab 12:27–31, 1999

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    ARBs are category C (risk cannot be ruled out) in the first trimester but category D (positive evidence of risk) in later pregnancy and should generally be discontinued before pregnancy.

    “ARBs are category C (risk cannot be ruled out) in the first trimester but category D (positive evidence of risk) in later pregnancy and should generally be discontinued before pregnancy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Among the oral antidiabetic agents, metformin and acarbose are classified as category B (no evidence of risk in humans) and all others as category C.

    “Among the oral antidiabetic agents, metformin and acarbose are classified as category B (no evidence of risk in humans) and all others as category C.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The incidence of type 2 diabetes in adolescents is increasing, especially in ethnic minority populations.

    “The incidence of type 2 diabetes in adolescents is increasing, especially in ethnic minority populations (20).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Dabelea D, Bell RA, D'Agostino RB Jr, Imperatore G, Johansen JM, Linder B, Liu LL, Loots B, Marcovina S, Mayer-Davis EJ, Pettitt DJ, Waitzfelder B: Incidence of diabetes in youth in the United States. JAMA 297:2716–2724, 2007

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.

    “These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia and with reduced linear growth.

    “Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia (296) and with reduced linear growth (297).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [296] Mohn A, Di Michele S, Di Luzio R, Tumini S, Chiarelli F: The effect of subclinical hypothyroidism on metabolic control in children and adolescents with type 1 diabetes mellitus. Diabet Med 19:70–73, 2002 source

      Not checked in the free run.

    • cites [297] Chase HP, Garg SK, Cockerham RS, Wilcox WD, Walravens PA: Thyroid hormone replacement and growth of children with subclinical hypothyroidism and diabetes. Diabet Med 7:299–303, 1990 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Hyperthyroidism alters glucose metabolism, potentially resulting in deterioration of metabolic control.

    “Hyperthyroidism alters glucose metabolism, potentially resulting in deterioration of metabolic control.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Statins are category X (contraindicated for use in pregnancy) and should be discontinued before conception, as should ACE inhibitors.

    “Statins are category X (contraindicated for use in pregnancy) and should be discontinued before conception, as should ACE inhibitors (304).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [304] Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S, Gideon PS, Hall K, Ray WA: Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med 354:2443–2451, 2006 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Distinction between type 1 and type 2 diabetes in children can be difficult, since the prevalence of overweight in children continues to rise and since autoantigens and ketosis may be present in a substantial number of patients with features of type 2 diabetes.

    “Distinction between type 1 and type 2 diabetes in children can be difficult, since the prevalence of overweight in children continues to rise and since autoantigens and ketosis may be present in a substantial number of patients with features of type 2 diabetes (including obesity and acanthosis nigricans).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    In patients without a prior history of diabetes, admission hyperglycemia could represent an unmasking of risk in a population at high risk for diabetes or more severe illness at admission.

    “In patients without a prior history of diabetes, admission hyperglycemia could represent case finding of patients with previously undiagnosed diabetes, an unmasking of risk in a population at high risk for diabetes or more severe illness at admission.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In the year 2003, there were 5.1 million hospitalizations with diabetes as a listed diagnosis, a 2.3-fold increase over 1980 rates.

    “In the year 2003, there were 5.1 million hospitalizations with diabetes as a listed diagnosis, a 2.3-fold increase over 1980 rates (314).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [314] Centers for Disease Control and Prevention: Hospitalizations for Diabetes as Any-Listed Diagnosis. National Diabetes Surveillance System. Atlanta, Georgia, Centers for Disease Control and Prevention, 2003

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The prevalence of diabetes in hospitalized adult patients is not precisely known.

    “The prevalence of diabetes in hospitalized adult patients is not precisely known.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    When admissions on general medicine and surgery units were studied, patients with new hyperglycemia had significantly increased in-hospital mortality, as did patients with known diabetes.

    “When admissions on general medicine and surgery units were studied, patients with new hyperglycemia had significantly increased in-hospital mortality, as did patients with known diabetes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [316] Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE: Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978–982, 2002 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Insulin use requires that patients or caregivers have good visual and motor skills and cognitive ability.

    “Insulin use requires that patients or caregivers have good visual and motor skills and cognitive ability.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    In the year 2000, 12.4% of hospital discharges in the U.S. listed diabetes as a diagnosis, but this is likely an underestimate.

    “In the year 2000, 12.4% of hospital discharges in the U.S. listed diabetes as a diagnosis, but this is likely an underestimate.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The prevalence of diabetes in hospitalized adults is conservatively estimated at 12-25%, depending on the thoroughness used in identifying patients.

    “The prevalence of diabetes in hospitalized adults is conservatively estimated at 12–25%, depending on the thoroughness used in identifying patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    There is less evidence for lipid-lowering and aspirin therapy, although the benefits of these interventions for primary and secondary prevention are likely to apply to older adults whose life expectancies equal or exceed the time frames seen in clinical trials.

    “There is less evidence for lipid-lowering and aspirin therapy, although the benefits of these interventions for primary and secondary prevention are likely to apply to older adults whose life expectancies equal or exceed the time frames seen in clinical trials.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Higher admission plasma glucose levels in patients with a prior history of diabetes could reflect the degree of glycemic control in the outpatient setting, thus linking outpatient glycemic control to outcomes in the inpatient population.

    “Higher admission plasma glucose levels in patients with a prior history of diabetes could reflect the degree of glycemic control in the outpatient setting, thus linking outpatient glycemic control to outcomes in the inpatient population.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The management of hyperglycemia in the hospital was traditionally considered secondary in importance to the condition that prompted admission.

    “The management of hyperglycemia in the hospital was traditionally considered secondary in importance to the condition that prompted admission (313).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [313] ACE/ADA Task Force on Inpatient Diabetes: American College of Endocrinology and American Diabetes Association Consensus statement on inpatient diabetes and glycemic control: a call to action. Diabetes Care 29:1955–1962, 2006 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Attainment of targeted glucose control in patients with diabetes undergoing cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections.

    “Attainment of targeted glucose control in patients with diabetes undergoing cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections (324,325).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [324] Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, Floten HS, Starr A: Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:1007–1021, 2003 source

      Not checked in the free run.

    • cites [325] Furnary AP, Zerr KJ, Grunkemeier GL, Starr A: Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67:352–360, 1999 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Intensive insulin therapy achieved a mean blood glucose of 103 mg/dl and was associated with reduced mortality during the ICU stay and decreased overall in-hospital mortality.

    “Intensive insulin therapy achieved a mean blood glucose of 103 mg/dl (5.7 mmol/l) and was associated with reduced mortality during the ICU stay and decreased overall in-hospital mortality (328).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [328] van den BG, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R: Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367, 2001 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    The studies of targeted glucose control in cardiac surgery used historical controls and were not randomized.

    “Although these studies used historical controls and were not randomized, they support the concept that perioperative hyperglycemia is an independent predictor of infection in patients with diabetes (326), with the lowest mortality in patients with blood glucose <150 mg/dl (8.3 mmol/l) (327).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [324] Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, Floten HS, Starr A: Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:1007–1021, 2003 source

      Not checked in the free run.

    • cites [325] Furnary AP, Zerr KJ, Grunkemeier GL, Starr A: Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67:352–360, 1999 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Hospital and ICU survival were linearly associated with ICU glucose levels, with the highest survival rates occurring in patients achieving an average blood glucose <110 mg/dl.

    “Hospital and ICU survival were linearly associated with ICU glucose levels, with the highest survival rates occurring in patients achieving an average blood glucose <110 mg/dl (6.1 mmol/l) (329).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [329] van den BG, Wouters PJ, Bouillon R, Weekers F, Verwaest C, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P: Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med 31:359–366, 2003 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There were more episodes of hypoglycemia (blood glucose <40 mg/dl) and more serious adverse events in the group receiving intensive insulin therapy in the sepsis study.

    “There were more episodes of hypoglycemia, defined as a blood glucose <40 mg/dl (2.2 mmol/l), and more serious adverse events in the group receiving intensive insulin therapy (331).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [331] Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K: Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139, 2008 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Whether glucose is simply a marker of the severity of underlying illness or a mediator of adverse outcomes is unclear.

    “Epidemiologic and physiologic data suggest that higher blood glucose levels are associated with worse outcomes, but whether glucose is simply a marker of the severity of underlying illness or a mediator of adverse outcomes is unclear.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In that medical ICU study, death rates were significantly lower in those patients who were treated for longer than 3 days; but these patients could not be identified before therapy.

    “Death rates were significantly lower in those patients who were treated for longer than 3 days; but these patients could not be identified before therapy.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [330] van den BG, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R: Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461, 2006 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An earlier meta-analysis concluded that insulin therapy in critically ill patients had a beneficial effect on short-term mortality in different clinical settings.

    “While an earlier meta-analysis concluded that insulin therapy in critically ill patients had a beneficial effect on short-term mortality in different clinical settings (332), a more recent meta-analysis, involving 29 studies and over 8,000 patients, failed to show any mortality benefit from intensive glucose control.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [332] Pittas AG, Siegel RD, Lau J: Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 164:2005–2011, 2004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A subsequent study of a similar intervention in patients in a medical ICU showed that the group receiving intensive insulin therapy had reduced morbidity but no difference in mortality overall.

    “A subsequent study of a similar intervention in patients in a medical ICU (330) showed that the group receiving intensive insulin therapy had reduced morbidity but no difference in mortality overall.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [330] van den BG, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R: Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461, 2006 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Since 1994 the ADA has not endorsed any single meal plan or specified percentages of macronutrients.

    “However, since 1994 the ADA has not endorsed any single meal plan or specified percentages of macronutrients, and the term “ADA diet” should no longer be used.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Despite the preventable nature of many inpatient episodes of hypoglycemia, institutions are more likely to have nursing protocols for the treatment of hypoglycemia than for its prevention.

    “Despite the preventable nature of many inpatient episodes of hypoglycemia, institutions are more likely to have nursing protocols for the treatment of hypoglycemia than for its prevention.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    The only method of insulin delivery specifically developed for use in the hospital is continuous intravenous infusion, using regular crystalline insulin.

    “The only method of insulin delivery specifically developed for use in the hospital is continuous intravenous infusion, using regular crystalline insulin.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Additional triggering events leading to iatrogenic hypoglycemia include sudden reduction of corticosteroid dose, altered ability of the patient to self-report symptoms, reduction of oral intake, emesis, new NPO status, inappropriate timing of short- or rapid-acting insulin in relation to meals, reduction of rate of administration of intravenous dextrose, and unexpected interruption of enteral feed

    “Additional triggering events leading to iatrogenic hypoglycemia include sudden reduction of corticosteroid dose, altered ability of the patient to self-report symptoms, reduction of oral intake, emesis, new NPO status, inappropriate timing of short- or rapid-acting insulin in relation to meals, reduction of rate of administration of intravenous dextrose, and unexpected interruption of enteral feed”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Current nutrition recommendations advise individualization based on treatment goals, physiologic parameters, and medication usage.

    “Current nutrition recommendations advise individualization based on treatment goals, physiologic parameters, and medication usage.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [351] American Diabetes Association: Diabetes nutrition recommendations for health care institutions (Position Statement). Diabetes Care 27 (Suppl. 1):S55–S57, 2004 source

      Not checked in the free run.

    • cites [352] Boucher JL, Swift CS, Franz MJ, Kulkarni K, Schafer RG, Pritchett E, Clark NG: Inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional. J Am Diet Assoc 107:105–111, 2007 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    TZDs increase intravascular volume, a particular problem in those predisposed to CHF and potentially a problem for patients with hemodynamic changes related to admission diagnoses or interventions common in hospitalized patients.

    “In addition, they increase intravascular volume, a particular problem in those predisposed to CHF and potentially a problem for patients with hemodynamic changes related to admission diagnoses (e.g., acute coronary ischemia) or interventions common in hospitalized patients.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Inpatient diabetes management may be effectively provided by primary care physicians, endocrinologists, or hospitalists, but involvement of appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes.

    “Inpatient diabetes management may be effectively provided by primary care physicians, endocrinologists, or hospitalists, but involvement of appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes (346–349).”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [346] Markovitz LJ, Wiechmann RJ, Harris N, Hayden V, Cooper J, Johnson G, Harelstad R, Calkins L, Braithwaite SS: Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery. EndocrPract 8:10–18, 2002 source

      Not checked in the free run.

    • cites [347] Levetan CS, Salas JR, Wilets IF, Zumoff B: Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med 99:22–28, 1995 source

      Not checked in the free run.

    • cites [348] Levetan CS, Passaro MD, Jablonski KA, Ratner RE: Effect of physician specialty on outcomes in diabetic ketoacidosis. Diabetes Care 22:1790–1795, 1999 source

      Not checked in the free run.

    • cites [349] Koproski J, Pretto Z, Poretsky L: Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care 20:1553–1555, 1997 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Implementation of standardized order sets for scheduled and correction-dose insulin may reduce reliance on sliding-scale management.

    “In the care of diabetes, implementation of standardized order sets for scheduled and correction-dose insulin may reduce reliance on sliding-scale management.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The patients in the basal-bolus insulin study were obese, and the doses used (0.4 to 0.5 units · kg · day−1) are higher than what may be required in patients who are more sensitive to insulin, such as those who are lean or who have type 1 diabetes.

    “It is important to note that the patients in this study were obese, and the doses used in this study (0.4 to 0.5 units · kg · day−1) are higher than what may be required in patients who are more sensitive to insulin, such as those who are lean or who have type 1 diabetes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [342] Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, Puig A, Mejia R: Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 30:2181–2186, 2007 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Hospital diets continue to be ordered by calorie levels based on the "ADA diet."

    “Hospital diets continue to be ordered by calorie levels based on the “ADA diet.””
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    For patients who are eating, commonly recommended testing frequencies are premeal and at bedtime.

    “For patients who are eating, commonly recommended testing frequencies are premeal and at bedtime.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    The diabetes camping experience is short term, with food and activity different than the home environment.

    “The diabetes camping experience is short term, with food and activity different than the home environment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Bedside blood glucose testing is usually performed with portable meters that are similar or identical to devices for home SMBG.

    “Bedside blood glucose testing is usually performed with portable meters that are similar or identical to devices for home SMBG.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Effects on important intermediate outcomes, such as mean A1C for populations, have been more difficult to demonstrate, although examples do exist.

    “Effects on important intermediate outcomes, such as mean A1C for populations, have been more difficult to demonstrate (363–365), although examples do exist (366–370).”
    Quote in the paperNot a substantial claim0 of 8 sources checked
    • cites [363] Clark CM Jr, Snyder JW, Meek RL, Stutz LM, Parkin CG: A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care 24:1079–1086, 2001 source

      Not checked in the free run.

    • cites [364] Meigs JB, Cagliero E, Dubey A, Murphy-Sheehy P, Gildesgame C, Chueh H, Barry MJ, Singer DE, Nathan DM: A controlled trial of web-based diabetes disease management: the MGH diabetes primary care improvement project. Diabetes Care 26:750–757, 2003 source

      Not checked in the free run.

    • cites [365] O'Connor PJ, Desai J, Solberg LI, Reger LA, Crain AL, Asche SE, Pearson TL, Clark CK, Rush WA, Cherney LM, Sperl-Hillen JM, Bishop DB: Randomized trial of quality improvement intervention to improve diabetes care in primary care settings. Diabetes Care 28:1890–1897, 2005 source

      Not checked in the free run.

    • cites [366] Sperl-Hillen JM, O'Connor PJ: Factors driving diabetes care improvement in a large medical group: ten years of progress. Am J Manag Care 11:S177–S185, 2005

      Not checked in the free run.

    • cites [367] Siminerio LM: Implementing diabetes self-management training programs: breaking through the barriers in primary care. Endocr Pract 12 (Suppl. 1):124–130, 2006 source

      Not checked in the free run.

    • cites [368] Mahoney JJ: Reducing patient drug acquisition costs can lower diabetes health claims. Am J Manag Care 11:S170–S176, 2005

      Not checked in the free run.

    • cites [369] Maney M, Tseng CL, Safford MM, Miller DR, Pogach LM: Impact of self-reported patient characteristics upon assessment of glycemic control in the Veterans Health Administration. Diabetes Care 30:245–251, 2007 source

      Not checked in the free run.

    • cites [370] Bergenstal RM: Treatment models from the International Diabetes Center: advancing from oral agents to insulin therapy in type 2 diabetes. Endocr Pract 12 (Suppl. 1):98–104, 2006 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Patients on continuous intravenous insulin typically require hourly blood glucose testing until the blood glucose levels are stable, then every 2 h.

    “Patients on continuous intravenous insulin typically require hourly blood glucose testing until the blood glucose levels are stable, then every 2 h.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Implementing intensive diabetes therapy in the hospital setting requires frequent and accurate blood glucose data.

    “Implementing intensive diabetes therapy in the hospital setting requires frequent and accurate blood glucose data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Staff training and ongoing quality control activities are important components of ensuring accuracy of the results.

    “Staff training and ongoing quality control activities are important components of ensuring accuracy of the results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The challenge of providing uniformly effective diabetes care has thus far defied a simple solution.

    “the challenge of providing uniformly effective diabetes care has thus far defied a simple solution”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    For patients not eating, testing every 4-6 h is usually sufficient for determining correction insulin doses.

    “For patients not eating, testing every 4–6 h is usually sufficient for determining correction insulin doses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Because camp is often associated with more physical activity than experienced at home, the insulin dose may have to be decreased during camp.

    “Because camp is often associated with more physical activity than experienced at home, the insulin dose may have to be decreased during camp.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Camp is often associated with more physical activity than experienced at home.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of health care professionals.

    “it is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of health care professionals.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The difficulties encountered by people with diabetes and their health care providers in the wake of Hurricane Katrina highlight the need for people with diabetes to be prepared for emergencies, whether natural or otherwise, affecting a region or just their household.

    “The difficulties encountered by people with diabetes and their health care providers in the wake of Hurricane Katrina (359) highlight the need for people with diabetes to be prepared for emergencies, whether natural or otherwise, affecting a region or just their household.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [359] Cefalu WT, Smith SR, Blonde L, Fonseca V: The Hurricane Katrina aftermath and its impact on diabetes care: observations from “ground zero”: lessons in disaster preparedness of people with diabetes. Diabetes Care 29:158–160, 2006 source

      Not checked in the free run.

153 of 153

  • The paper relies on this without support.

    The 75-g oral glucose tolerance test is more sensitive and modestly more specific than the fasting plasma glucose test for diagnosing diabetes.

    “Although the 75-g oral glucose tolerance test (OGTT) is more sensitive and modestly more specific than the fasting plasma glucose (FPG) to diagnose diabetes, it is poorly reproducible and difficult to perform in practice.”

  • The paper relies on this without support.

    The 75-g oral glucose tolerance test is poorly reproducible and difficult to perform in practice.

    “Although the 75-g oral glucose tolerance test (OGTT) is more sensitive and modestly more specific than the fasting plasma glucose (FPG) to diagnose diabetes, it is poorly reproducible and difficult to perform in practice.”

  • The paper relies on this without support.

    The duration of glycemic burden is a strong predictor of adverse outcomes.

    “Additionally, the duration of glycemic burden is a strong predictor of adverse outcomes, and effective interventions exist to prevent progression of pre-diabetes to diabetes (see Section IV) and to reduce risk of complications of diabetes (see Section VI).”

  • The paper relies on this without support.

    Approximately 7% of all pregnancies are complicated by gestational diabetes mellitus, resulting in more than 200,000 cases annually.

    “Approximately 7% of all pregnancies (ranging from 1 to 14% depending on the population studied and the diagnostic tests employed) are complicated by GDM, resulting in more than 200,000 cases annually.”

  • The paper relies on this without support.

    Gestational diabetes mellitus carries risks to the mother and neonate.

    “Because of the risks of GDM to the mother and neonate, screening and diagnosis are warranted.”

  • The paper relies on this without support.

    Continuous glucose monitoring through the measurement of interstitial glucose correlates well with plasma glucose.

    “CGM through the measurement of interstitial glucose (which correlates well with plasma glucose) is available.”

  • The paper relies on this without support.

    Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed.

    “Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed.”

  • The paper relies on this without support.

    Pre-diabetes and diabetes are common, increasing in prevalence, and impose significant public health burdens.

    “Both conditions are common, increasing in prevalence, and impose significant public health burdens.”

  • The paper relies on this without support.

    There is a long presymptomatic phase before the diagnosis of type 2 diabetes is usually made.

    “There is a long presymptomatic phase before the diagnosis of type 2 diabetes is usually made.”

  • The paper relies on this without support.

    Age is a major risk factor for diabetes.

    “Because age is a major risk factor for diabetes, testing of those without other risk factors should begin no later than age 45 years.”

  • The paper relies on this without support.

    There is little likelihood that an individual will develop significant complications of diabetes within 3 years of a negative test result.

    “The rationale for the 3-year interval is that false-negatives will be repeated before substantial time elapses, and there is little likelihood that an individual will develop significant complications of diabetes within 3 years of a negative test result.”

  • The paper relies on this without support.

    The observational glycemia-CVD risk curves have a flatter part at A1C levels of approximately 6.4–8.4%.

    “The three trials compared treatments to A1C levels in the “flatter” part of the observational glycemia-CVD risk curves (median A1C of 6.4–6.9% in the intensive arms compared with 7.0–8.4% in the standard arms).”

  • The paper relies on this without support.

    In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not altered.

    “In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not altered.”

  • The paper relies on this without support.

    Hypoglycemia is rare in diabetic individuals who are not treated with insulin or insulin secretagogues.

    “Hypoglycemia is rare in diabetic individuals who are not treated with insulin or insulin secretagogues, and no preventive measures for hypoglycemia are usually advised in these cases.”

  • The paper relies on this without support.

    Infection or dehydration are more likely to necessitate hospitalization of the person with diabetes than the person without diabetes.

    “Infection or dehydration are more likely to necessitate hospitalization of the person with diabetes than the person without diabetes.”

  • The paper relies on this without support.

    CVD is the major cause of morbidity and mortality for individuals with diabetes and the largest contributor to the direct and indirect costs of diabetes.

    “CVD is the major cause of morbidity and mortality for individuals with diabetes and the largest contributor to the direct and indirect costs of diabetes.”

  • The paper relies on this without support.

    Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity.

    “Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity.”

  • The paper relies on this without support.

    Most patients with hypertension require multi-drug therapy to reach treatment goals, especially diabetic patients whose targets are lower.

    “An important caveat is that most patients with hypertension require multi-drug therapy to reach treatment goals, especially diabetic patients whose targets are lower.”

  • The paper relies on this without support.

    Lower blood pressure levels may be associated with impaired fetal growth.

    “Lower blood pressure levels may be associated with impaired fetal growth.”

  • The paper relies on this without support.

    During pregnancy, treatment with ACE inhibitors and ARBs is contraindicated, since they are likely to cause fetal damage.

    “During pregnancy, treatment with ACE inhibitors and ARBs is contraindicated, since they are likely to cause fetal damage.”

  • The paper relies on this without support.

    Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin.

    “Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin.”

  • The paper relies on this without support.

    Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD.

    “Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD.”

  • The paper relies on this without support.

    Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes.

    “Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in persons with type 2 diabetes.”

  • The paper relies on this without support.

    Glycemic control can beneficially modify plasma lipid levels, particularly in patients with very high triglycerides and poor glycemic control.

    “Glycemic control can also beneficially modify plasma lipid levels, particularly in patients with very high triglycerides and poor glycemic control.”

  • The paper relies on this without support.

    Very little clinical trial evidence exists for type 2 patients under the age of 40, or for type 1 patients of any age.

    “Very little clinical trial evidence exists for type 2 patients under the age of 40, or for type 1 patients of any age.”

  • The paper relies on this without support.

    Niacin, fenofibrate, ezetimibe, and bile acid sequestrants all offer additional LDL cholesterol lowering.

    “Niacin, fenofibrate, ezetimibe, and bile acid sequestrants all offer additional LDL cholesterol lowering.”

  • The paper relies on this without support.

    The evidence that combination therapy provides a significant increment in CVD risk reduction over statin therapy alone is still elusive.

    “The evidence that combination therapy provides a significant increment in CVD risk reduction over statin therapy alone is still elusive.”

  • The paper relies on this without support.

    Niacin is the most effective drug for raising HDL cholesterol.

    “Niacin is the most effective drug for raising HDL cholesterol.”

  • The paper relies on this without support.

    Diabetic nephropathy occurs in 20–40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD).

    “Diabetic nephropathy occurs in 20–40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD).”

  • The paper relies on this without support.

    Persistent albuminuria in the range of 30–299 mg/24 h (microalbuminuria) is the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes.

    “Persistent albuminuria in the range of 30–299 mg/24 h (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes.”

  • The paper relies on this without support.

    Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to the duration of diabetes.

    “Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to the duration of diabetes.”

  • The paper relies on this without support.

    Up to 50% of DPN may be asymptomatic, and patients are at risk of insensate injury to their feet.

    “up to 50% of DPN may be asymptomatic, and patients are at risk of insensate injury to their feet”

  • The paper relies on this without support.

    Cardiovascular autonomic neuropathy causes substantial morbidity and mortality.

    “cardiovascular autonomic neuropathy causes substantial morbidity and mortality”

  • The paper relies on this without support.

    Specific treatment for the underlying nerve damage is currently not available, other than improved glycemic control, which may slow progression but not reverse neuronal loss.

    “Specific treatment for the underlying nerve damage is currently not available, other than improved glycemic control, which may slow progression but not reverse neuronal loss.”

  • The paper relies on this without support.

    Amputation and foot ulceration, consequences of diabetic neuropathy and/or PAD, are common and major causes of morbidity and disability in people with diabetes.

    “Amputation and foot ulceration, consequences of diabetic neuropathy and/or PAD, are common and major causes of morbidity and disability in people with diabetes.”

  • The paper relies on this without support.

    The risk of ulcers or amputations is increased in people with previous amputation, past foot ulcer history, peripheral neuropathy, foot deformity, peripheral vascular disease, vision impairment, diabetic nephropathy, poor glycemic control, or cigarette smoking.

    “The risk of ulcers or amputations is increased in people who have the following risk factors: previous amputationpast foot ulcer historyperipheral neuropathyfoot deformityperipheral vascular diseasevision impairmentdiabetic nephropathy (especially patients on dialysis)poor glycemic controlcigarette smoking”

  • The paper relies on this without support.

    Three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age.

    “Three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age.”

  • The paper relies on this without support.

    Children with diabetes differ from adults in insulin sensitivity related to sexual maturity and physical growth, ability to provide self-care, supervision in child care and school, and unique neurologic vulnerability to hypoglycemia and DKA.

    “Children with diabetes differ from adults in many respects, including changes in insulin sensitivity related to sexual maturity and physical growth, ability to provide self-care, supervision in child care and school, and unique neurologic vulnerability to hypoglycemia and DKA.”

  • The paper relies on this without support.

    Most children <6 or 7 years of age have a form of hypoglycemic unawareness.

    “most children <6 or 7 years of age have a form of hypoglycemic unawareness.”

  • The paper relies on this without support.

    No statin is approved for use under the age of 10.

    “No statin is approved for use under the age of 10”

  • The paper relies on this without support.

    Retinopathy has been reported in prepubertal children and with diabetes duration of only 1–2 years.

    “it has been reported in prepubertal children and with diabetes duration of only 1–2 years.”

  • The paper relies on this without support.

    Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition due to malabsorption, and other gastrointestinal problems and unexplained hypoglycemia or erratic blood glucose concentrations.

    “Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition due to malabsorption, and other gastrointestinal problems and unexplained hypoglycemia or erratic blood glucose concentrations.”

  • The paper relies on this without support.

    Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes.

    “Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with type 1 and type 2 diabetes.”

  • The paper relies on this without support.

    Nearly two-thirds of pregnancies in women with diabetes are unplanned, leading to a persistent excess of malformations in infants of diabetic mothers.

    “nearly two-thirds of pregnancies in women with diabetes are unplanned, leading to a persistent excess of malformations in infants of diabetic mothers.”

  • The paper relies on this without support.

    At least 20% of patients over the age of 65 years have diabetes, and this number can be expected to grow rapidly in the coming decades.

    “at least 20% of patients over the age of 65 years have diabetes, and this number can be expected to grow rapidly in the coming decades.”

  • The paper relies on this without support.

    Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, CHD, and stroke than those without diabetes.

    “Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, CHD, and stroke than those without diabetes.”

  • The paper relies on this without support.

    Life expectancies are highly variable for older adults with diabetes, but often longer than clinicians realize.

    “Life expectancies are highly variable for this population, but often longer than clinicians realize.”

  • The paper relies on this without support.

    Metformin is often contraindicated because of renal insufficiency or significant heart failure.

    “Metformin is often contraindicated because of renal insufficiency or significant heart failure.”

  • The paper relies on this without support.

    TZDs can cause fluid retention, which may exacerbate or lead to heart failure.

    “TZDs can cause fluid retention, which may exacerbate or lead to heart failure.”

  • The paper relies on this without support.

    Sulfonylureas, other insulin secretagogues, and insulin can cause hypoglycemia.

    “Sulfonylureas, other insulin secretagogues, and insulin can cause hypoglycemia.”

  • The paper relies on this without support.

    No large studies have investigated the potential roles of various noninsulin glucose-lowering agents on outcomes of hospitalized patients with diabetes.

    “No large studies have investigated the potential roles of various noninsulin glucose-lowering agents on outcomes of hospitalized patients with diabetes.”

  • The paper relies on this without support.

    Camp is often associated with more physical activity than experienced at home.

    “Because camp is often associated with more physical activity than experienced at home, the insulin dose may have to be decreased during camp.”

  • The paper relies on this without support.

    Insulin-treated individuals with diabetes are at highest risk for hypo- and hyperglycemia and DKA.

    “rapid identification of all insulin-treated individuals with diabetes is essential in order to identify those at highest risk for hypo- and hyperglycemia and DKA.”

  • The paper relies on this without support.

    A hiatus in either medication or appropriate nutrition may lead to severe hyper- or hypoglycemia.

    “a hiatus in either medication or appropriate nutrition may lead to either severe hyper- or hypoglycemia.”

  • The paper relies on this without support.

    The frequency of CBG monitoring will vary by patients’ glycemic control and diabetes regimens.

    “The frequency of CBG monitoring will vary by patients’ glycemic control and diabetes regimens.”

  • The paper relies on this without support.

    Disaster preparedness will lessen the impact an emergency may have on the condition of people with diabetes.

    “Such preparedness will lessen the impact an emergency may have on their condition.”

  • The paper relies on this without support.

    For most types of employment, there is no reason to believe that an individual's diabetes will put employees or the public at risk.

    “For most types of employment, there is no reason to believe that the individual's diabetes will put employees or the public at risk.”

  • The paper relies on this without support.

    In certain safety-sensitive positions, the safety concern is whether the employee will become suddenly disoriented or incapacitated.

    “In certain safety-sensitive positions the safety concern is whether the employee will become suddenly disoriented or incapacitated.”

  • The paper relies on this without support.

    Hyperglycemia is not typically a barrier to employment unless long-term complications are present that interfere with job performance.

    “Hyperglycemia is not typically a barrier to employment unless long-term complications are present that interfere with the performance of the job.”

  • The paper relies on this without support.

    Most accommodations that help an individual with diabetes do his or her job may be provided easily and with little or no cost to the employer.

    “Most accommodations that help an individual with diabetes do his or her job may be provided easily and with little or no cost to the employer.”

  • The paper relies on this without support.

    Treatments and therapies that improve glycemic control and reduce the complications of diabetes will also significantly reduce health care costs.

    “Treatments and therapies that improve glycemic control and reduce the complications of diabetes will also significantly reduce health care costs.”

  • The paper relies on this without support.

    Medicare and many other third-party payors cover DSME and MNT.

    “Medicare and many other third-party payors cover DSME (Centers for Medicare and Medicaid Services [CMS] term is diabetes self-management training [DSMT]) that meets the national standards for DSME (107) and MNT.”

  • The paper relies on this without support.

    The qualified beneficiary can receive an initial benefit of 10 h of DSMT and 3 h of MNT, with a potential total of 13 h of initial.

    “The qualified beneficiary, with referral from the provider managing his or her diabetes, can receive an initial benefit of 10 h of DSMT and 3 h of MNT, with a potential total of 13 h of initial.”

  • The paper relies on this without support.

    Without appropriate safeguards, undue controls could constitute an obstruction of effective care.

    “Without appropriate safeguards, undue controls could constitute an obstruction of effective care.”

  • The paper relies on this without support.

    Successful programs have published results showing improvement in process measures such as measurement of A1C, lipids, and blood pressure.

    “Successful programs have published results showing improvement in process measures such as measurement of A1C, lipids, and blood pressure.”

  • The paper relies on this without support.

    Successful interventions have been focused at the level of health care professionals, delivery systems, and patients.

    “Successful interventions have been focused at the level of health care professionals, delivery systems, and patients.”

  • The paper relies on this without support.

    Delivery of DSME has been shown to increase adherence to standard of care.

    “Delivery of DSME, which has been shown to increase adherence to standard of care.”

  • The paper relies on this without support.

    Use of checklists that mirror guidelines has been successful at improving adherence to standards of care.

    “Use of checklists that mirror guidelines have been successful at improving adherence to standards of care.”

  • The paper relies on this without support.

    Tracking systems with either an electronic medical record or patient registry have been helpful at increasing adherence to standards of care by prospectively identifying those requiring assessments and/or treatment modifications.

    “Tracking systems with either an electronic medical record or patient registry have been helpful at increasing adherence to standards of care by prospectively identifying those requiring assessments and/or treatment modifications.”

  • The paper relies on this without support.

    A variety of nonautomated systems, such as mailing reminders to patients, chart stickers, and flow sheets, have been useful to prompt both providers and patients.

    “A variety of nonautomated systems, such as mailing reminders to patients, chart stickers, and flow sheets, have been useful to prompt both providers and patients.”

  • The paper relies on this without support.

    Nurses, pharmacists, and other nonphysician health care professionals using detailed algorithms working under the supervision of physicians and/or nurse education calls have also been helpful.

    “Nurses, pharmacists, and other nonphysician health care professionals using detailed algorithms working under the supervision of physicians and/or nurse education calls have also been helpful.”

  • The paper relies on this without support.

    Dietitians using MNT guidelines have been demonstrated to improve glycemic control.

    “Similarly, dietitians using MNT guidelines have been demonstrated to improve glycemic control.”

  • The paper relies on this without support.

    Evidence suggests that individual initiatives work best when provided as components of a multifactorial intervention.

    “Evidence suggests that these individual initiatives work best when provided as components of a multifactorial intervention.”
73 of 73

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  • ADAG trial is cited as reference 49, which is a UKPDS paper

    Minor

    The text assigns reference 49 to the ADAG trial, but reference 49 is a UKPDS study of metformin. The ADAG study appears in the reference list as number 42.

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References 390 · Cited by 2,167

Research works printed but not linked: 2

  1. Singh IM, Shishehbor MH, Ansell BJ: High-density lipoprotein as a therapeutic target: a systematic review. JAMA 298:786–798, 2007 · DOI · Paper page
  2. American Association of Clinical Endocrinologists: Inpatient diabetes and metabolic control: conference proceedings. Endocr Pract 10 (Suppl. 2):1–108, 2004

Authors
American Diabetes Association
Corresponding author
American Diabetes Association
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2009-01-01
Volume
32
Issue
Supplement_1
Pages
S13-S61
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/dc09-s013
PMC
PMC2613589
OpenAlex
W2626017884
Cited by
2,167
References
390
Citations by year
2026: 10 · 2025: 52 · 2024: 42 · 2023: 50 · 2022: 57 · 2021: 77 · 2020: 80 · 2019: 77 · 2018: 108 · 2017: 91 · 2016: 82 · 2015: 80 · 2014: 131 · 2013: 134 · 2012: 168
FWCI
224.02
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Diabetes Care (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
Funders
  • U.S. Department of Veterans Affairs
  • American Heart Association
  • Agency for Healthcare Research and Quality
  • National Heart, Lung, and Blood Institute
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
diabetes mellitus, diabetes management, clinical guidelines, glycemic control, diabetes complications, diabetes treatment
MeSH terms
Delivery of Health Care, Diabetes Mellitus, Humans, Medical Records, Physicians

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