Irl B. Hirsch, MD

When the current editorial team of Clinical Diabetes first met 2 1/2 years ago, we decided to regularly include in the journal reprints of the American Diabetes Association (ADA) position statements and consensus statements. These reports are initially published in ADA's journal Diabetes Care and are collected in an annual supplement to that journal titled "Clinical Practice Recommendations." Many are revised as new information becomes available.

Of all of the position statements, the most important is "Standards of Medical Care for Patients With Diabetes Mellitus." In our team's first issue in 1998, we reprinted this position statement. We do so again, in an abridged form, in this issue.

Originally published in 1988, this document has, by necessity, grown longer over the years. For example, within the past few years, we have collected new data about glucose control in type 2 diabetes, the epidemiology of heart disease in individuals with diabetes, and the need to be aggressive in treating hypertension and dyslipidemia. To remain current, the "Standards of Medical Care" have been revised to reflect our increased knowledge.

As a result, the most current version, published in January 2000, reflects the most important evidence-based collection of diabetes treatment recommendations. For example, the increased understanding of the importance of high-density lipoprotein cholesterol has resulted in a new recommendation for this lipoprotein as a secondary goal of therapy for dyslipidemia. The 2000 "Standards of Medical Care" also explain the important difference between whole blood and plasma glucose, and glycemic goals are provided for each of these measurements. The statement also includes information about cases in which recommended glycemic levels may not be appropriate (e.g., in very young or very old patients) and gives options to consider for patients with unacceptably high glycosylated hemoglobin levels (e.g., referral to an endocrinologist).

I consider the "Standards of Medical Care" one of the most important documents of the ADA. I have served on numerous committees through the years that attempted to develop their own care standards for their own communities. In almost all cases, the ADA standards are used as the basis for care. Why must we try to reinvent the wheel?

Perhaps the most controversial part of the ADA standards is how to best screen for coronary artery disease (CAD). The current recommendations are based on consensus conference recommendations that were published in 1998.¹ The conclusion of that conference was that, since electrocardiograms are not sensitive enough to document significant CAD in a population at a high risk of death from atherosclerosis, screens with stress tests should be considered for individuals with diabetes and other risk factors. More recently, the American Heart Association published similar guidelines for more aggressive detection of CAD.² It would be interesting to see how well we comply with this relatively new standard, especially considering how poorly we do with other standards of care that have been published for more than a decade.³

I encourage all readers of Clinical Diabetes to review this year's "Standards of Medical Care for Patients With Diabetes Mellitus." Because of space constraints, we have abridged the text of the statement in this issue. However, the entire document may be found in Diabetes Care⁴ or on the ADA Web site at http://www.diabetes.org/DiabetesCare/Supplement100/S32.htm

This document may be the most important article we publish in Clinical Diabetes. I hope you find it helpful to your practice.

  REFERENCES

¹American Diabetes Association: Consensus statement: Diagnosis of coronary heart disease in people with diabetes. Diabetes Care 21:1551-59, 1998.

Irl B. Hirsch, MD, is an associate professor of medicine and medical director of the Diabetes Care Center at the University of Washington School of Medicine in Seattle. He is editor-in-chief of Clinical Diabetes.