This document provides guidelines for screening, diagnosing, and managing diabetes and prediabetes. It outlines risk factors for developing type 2 diabetes and recommends criteria for testing asymptomatic adults. It describes normal, prediabetic, and diabetic ranges for blood glucose levels and A1C. The document recommends lifestyle changes like medical nutrition therapy, physical activity, and smoking cessation to prevent and treat diabetes. It provides guidelines for foot care, treating complications, immunizations, and managing related conditions like hypertension and dyslipidemia.

1. Clinical practice
DIABETES MELLITUS
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2. RISK FACTORS FOR PRE DIABETES AND T2D:
CRITERIA FOR TESTING FOR DIABETES IN
ASYMPTOMATIC ADULTS
• Age ≥45 years without other risk factors
• CVD or family history of T2D
• Overweight or obese
• Sedentary lifestyle
• Member of an at-risk racial or ethnic group: Asian, African
American, Hispanic, Native American (Alaska Natives and
American Indians), or Pacific Islander
• HDL-C <35 mg/dL (0.90 mmol/L) and/or a triglyceride level
>250 mg/dL (2.82 mmol/L)
• IGT, IFG, and/or metabolic syndrome
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3. • PCOS, NAFLD
• Hypertension (BP >140/90 mm Hg or on therapy for
hypertension)
• History of gestational diabetes or delivery of a baby
weighing more than 4 kg (9 lb)
• Antipsychotic therapy for schizophrenia and/or severe
bipolar disease
• Chronic glucocorticoid exposure
• Sleep disorders in the presence of glucose intolerance
(A1C >5.7%, IGT, or IFG on previous testing), including
OSA, chronic sleep deprivation, and night-shift occupation
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4. Normal High Risk for Diabetes Diabetes
FPG <100 mg/dL IFG
FPG ≥100-125 mg/dL
FPG ≥126 mg/dL
2-h PG <140 mg/dL IGT
2-h PG ≥140-199 mg/dL
2-h PG ≥200 mg/dL
Random PG ≥200
mg/dL +
symptoms
A1C <5.5% 5.5 to 6.4%
For screening of pre
diabetesa
≥6.5%
Secondary
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5. NON PHARMALOGICAL TREATMENT
LIFE STYLE CHANGES
I. Medical nutrition therapy
II. Physical activity
III. Smoking Cessation
Goals of nutrition:
• Healthful eating pattern to improve overall health
• Attain individualized glycaemic, BP, and lipid goals
• Achieve and maintain body weight goals
• Delay or prevent diabetes complications
• Improve insulin sensitivity.
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6. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS
HEALTHFUL EATING RECOMMENDATIONS FOR
PATIENTS WITH DIABETES MELLITUS
General eating habits
• Eat regular meals and snacks; avoid fasting to lose weight
• Consume plant-based diet (high in fiber, low calories/glycemic
index, and high in phytochemicals/antioxidants)
• Understand Nutrition Facts Label information
• Use mild cooking techniques instead of high-heat cooking
• Keep physician-patient discussions informal
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7. • Carbohydrate
• Explain the 3 types of carbohydrates—sugars,
starch, and fiber—and the effects on health for each
type Specify healthful carbohydrates (fresh fruits and
vegetables, legumes, whole grains); target 7-10
servings per day
• Lower-glycemic index foods may facilitate glycemic
control (glycemic index score <55 out of 100:
multigrain bread, pumpernickel bread, whole oats,
legumes, apple, lentils, chickpeas, mango, yams,
brown rice), but there is insufficient evidence to
support a formal recommendation to educate
patients that sugars have both positive and negative
health effects
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8. Fat
Specify healthful fats (low mercury/contaminant-
containing nuts, avocado, certain plant oils, fish)
Limit saturated fats (butter, fatty red meats, tropical
plant oils, fast foods) and trans fat; choose fat-free or
low-fat dairy products
Protein
• Consume protein in foods with low saturated fats
(fish, eggwhites, beans); there is no need to avoid
animal protein
• Avoid or limit processed meats
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9. MICRONUTRIENTS
Routine supplementation is not necessary; a
healthful eating
meal plan can generally provide sufficient
micronutrients Specifically, chromium;
vanadium; magnesium; vitamins A, C, and E;
Vitamin supplements should be recommended
to patients at risk of insufficiency or deficiency
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10. PHYSICAL ACTIVITY
ADULTS WITH DIABETES
Exercise programs should include
• ≥150 min/wk moderate-intensity aerobic activity (50%-70% max heart rate),
spread over≥3 days/wk with no more than 2 consecutive days without exercise
• Resistance training ≥2 times/wk (in absence of contraindications)
• Reduce sedentary time = break up >90 minutes spent sitting
• Evaluate patients for contraindications prohibiting certain types of exercise before
recommending exercise program†
• Consider age and previous level of physical activity
Children with diabetes or pre diabetes
• ≥60 min physical activity/day
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11. PHYSICAL ACTIVITY IN PATIENTS WITH NON
OPTIMAL GLYCEMIC CONTROL
• Hyperglycaemia
• Avoid vigorous activity with ketosis When individuals with type 1 diabetes are
deprived of insulin for 12-28 hours and are ketotic, exercise can worsen
hyperglycemia and ketosis
• Hypoglycemia
• If taking insulin, physical activity can cause hypoglycemia if medication dose or
carb consumption is not altered
• Added carbohydrates should be ingested when pre-exercise glucose is <100
mg/dL (5.6 mmol/L)
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12. PHYSICAL ACTIVITY CONSIDERATIONS FOR
PATIENTS WITH DIABETES COMPLICATIONS
• Retinopathy
If proliferative diabetic retinopathy or severe nonproliferative diabetic
retinopathy present Vigorous aerobic or resistance exercise may be
contraindicated
• Peripheral Neuropathy
Decreased pain sensation and a higher pain threshold in the extremities
cause increased risk of skin breakdown
All individuals with neuropathy should wear proper footwear and examine feet
daily for lesions
Foot injury or open sore: restricted to non-weight bearing activity
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13. Autonomic Neuropathy
• Physical activity can acutely increase urinary protein excretion
• No evidence that vigorous exercise increases rate of
progression of diabetic kidney disease
• Exercise restrictions not required
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14. CARDIOVASCULAR DISEASE (CVD) & DIABETES
• Management of Blood Pressure (Hypertension)
• Diabetes and hypertension: SBP <140 mm Hg Lower SBP targets (eg,
<130 mm Hg) may be appropriate in certain individuals if can be achieved without
treatment burden
• Diabetes: DBP <90 mm Hg Lower DBP (eg, 80 mm Hg) may be
appropriate in certain individuals if can be achieved without treatment burden)
• BP >120/80 mm Hg: lifestyle changes
Weight loss (if overweight)
DASH-style diet including sodium restriction and potassium increase
Moderate alcohol intake
Increased physical activity
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15. • BP >140/90 mm Hg: lifestyle changes + pharmacologic therapy
Diabetes and hypertension: ACEI or ARB*
≥2 agents at max doses, including thiazide-type diuretic, ACEI, or ARB, usually
required to achieve targets
Administer ≥1 agent at bedtime
ACEI, ARB, diuretic: monitor serum creatinine/eGFR and serum potassium
• Treatment and targets for pregnant women
Diabetes and hypertension: 110-129/65-79 mm Hg target
ACEI, ARB contraindicated
MANAGEMENT OF LIPIDS (DYSLIPIDAEMIA)
• Treatment initiation and initial dose driven by risk status—not LDL-C level
• Screening at diabetes diagnosis, initial medical evaluation, and/or at age 40
• Every 1-2 years thereafter
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16. DR SAYED HANOURA 16

17. FOOT CARE
• All individuals with diabetes
Annual foot exam to identify risk factors predictive of ulcers and
amputations
Assessment of foot pulses, loss of protective sensation (LOPS) testing
Provide foot self-care education
• Patients with foot ulcers, high-risk feet (previous ulcer or amputation)
Use multidisciplinary approach
• All individuals with insensate feet, foot deformities, or history of foot ulcers
Examine feet every visit
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18. DR SAYED HANOURA 18
• Refer to foot care specialist
People who smoke
LOPS and structural abnormalities
History of prior lower-extremity complications
• Include in initial PAD screening
History for claudication and assessment of pedal pulses
Obtain ankle-brachial index (ABI)
• Refer for further vascular assessment
Patients with positive ABI, significant claudication
Consider exercise, medications, surgical options

19. RECOMMENDATIONS FOR OTHER CLINICAL
ASPECTS
• Recommendations for nephropathy screening. All patients
should be screened for urine albumin excretion and estimated
GFR starting at diagnosis of type II diabetes and five years after
the diagnosis of type I diabetes and at least annually thereafter.
• Recommendations for retinopathy screening. All patients should
have a dilated and comprehensive eye examination by an
ophthalmologist or optometrist starting at diagnosis of type II
diabetes and within five years of diagnosis of type I diabetes and
at least annually thereafter. Less-frequent exams (every 2 years)
may be considered following one or more normal eye exams
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20. • Recommendations for energy balance, overweight, and
obesity. Promotion of weight loss through a healthful eating
pattern that includes a reduction of caloric intake is
recommended for overweight or obese individuals who have or
are at risk for diabetes.
• Recommendations for diabetes self-management
education (DSME) and support (DSMS). DSME and DSMS
should be provided to people with diabetes upon diagnosis and
as needed thereafter. Key outcomes of DSME and DSMS
include effective self-management and quality of life.
Psychosocial issues and emotional well-being should also be
addressed to promote optimal outcomes.
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21. • Recommendations for Immunizations. Immunize per the Centers for Disease
Control and Prevention (CDC) Advisory Committee on Immunization Practices
(ACIP) recommendations for the following vaccines:
Influenza
Pneumococcal
Hepatitis B
• Recommendations for psychosocial assessment and care. Psychological and
social situation assessment should be included in the medical management for
diabetes. Routinely screen for depression and condition-related distress, anxiety,
eating disorders, and cognitive impairment. Psychosocial screening should also
include attitudes about the condition, expectations of diabetes management and
outcomes, affect and mood, quality of life, resources (financial, social, and
emotional), and psychiatric history. Perform routine screening when diabetes is
diagnosed, during follow-up visits and hospitalizations, when new complications are
diagnosed, and when problems with diabetes control or diabetes self-management
arise.
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22. EVIDENCE-BASED GUIDELINE
DIABETIC NEUROPATHY
Treatment of painful diabetic neuropathy Report of the American Academy of
Neurology, the American Association of Neuromuscular and Electrodiagnostic
Medicine, and the American Academy of Physical Medicine and Rehabilitation
• Recommendations 1. Percutaneous electrical nerve stimulation should
be considered for the treatment of PDN (Level B).
• 2. Electromagnetic field treatment, low-intensity laser treatment, and
Reiki therapy should probably not be considered for the treatment
of PDN (Level B).
• 3. Evidence is insufficient to support or refute the use of amitriptyline
plus electrotherapy for treatment of PDN (Level U).
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23. DR SAYED HANOURA 23
thank you