ADA Diabetes Guidelines 2005–2009: How Diabetes Care Evolved

ADA Diabetes Guidelines 2005–2009: Historical Timeline

This timeline highlights major themes in the annual ADA Standards and important clinical research published during this period. A study published in a given year was not necessarily incorporated into the Standards issued at the beginning of that same year.

ADA Diabetes Guidelines 2005: Comprehensive Diabetes Management

The 2005 ADA Standards continued to treat diabetes as a chronic disease requiring regular follow-up, patient education and systematic assessment of complications.

Important elements included:

• Assessment and monitoring of blood glucose and A1C.
• Individualized nutrition planning and physical activity.
• Blood pressure and lipid management.
• Screening for diabetic kidney disease and retinopathy.
• Foot examinations and neuropathy assessment.
• Diabetes self-management education.

The historical significance of 2005 is not that these principles appeared for the first time. Rather, they formed an increasingly established framework for comprehensive diabetes care.

The original document is available in Standards of Medical Care in Diabetes — 2005.

ADA Diabetes Guidelines 2006: The ADA/EASD Treatment Algorithm

In 2006, the ADA published its annual Standards, emphasizing diabetes classification, diagnosis, prevention, glucose management and complication screening.

Later that year, ADA and the European Association for the Study of Diabetes (EASD) published a separate joint consensus statement on managing hyperglycemia in type 2 diabetes.

What did the 2006 ADA/EASD algorithm recommend?

The consensus proposed an organized, stepwise strategy for managing elevated blood glucose in type 2 diabetes. Its central elements included:

• Starting lifestyle intervention at diagnosis.
• Using metformin as a common initial glucose-lowering medication when suitable.
• Monitoring response to treatment.
• Intensifying treatment when glycemic goals were not met.
• Considering medication effectiveness, adverse effects and patient circumstances.

The original consensus was published in Diabetes Care in August 2006: Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm.

ADA Diabetes Guidelines 2007: Glucose Targets, Nutrition and Risk Factors

The 2007 ADA Standards continued emphasizing glycemic management alongside cardiovascular prevention and management of chronic diabetes complications.

Medical nutrition therapy remained an important component of diabetes care. The guidelines supported individualized nutrition plans rather than a single universal diabetes diet.

Other important priorities included:

• Regular A1C testing and home glucose monitoring when appropriate.
• Assessment of hypoglycemia risk.
• Management of elevated blood pressure and abnormal cholesterol.
• Assessment of kidney function and urinary albumin.
• Eye and foot examinations.
• Support for physical activity and smoking cessation.

The 2007 Standards reflected continued development of an integrated approach to diabetes, rather than focusing on glucose levels alone.

See the original 2007 ADA Standards.

ADA Diabetes Guidelines 2008: A Turning Point in Glucose-Control Research

The ADA's January 2008 Standards emphasized the importance of glucose control, individualized treatment goals and preventing microvascular complications.

However, important clinical trial results emerged later in 2008 that challenged assumptions about how aggressively blood glucose should be lowered in some people with longstanding type 2 diabetes.

The ACCORD trial

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial studied intensive versus standard glucose-lowering strategies in adults with type 2 diabetes and elevated cardiovascular risk.

In February 2008, the intensive glucose-control treatment strategy was stopped early after investigators identified higher mortality in the intensive-treatment group.

That finding did not mean glucose control was unimportant. It demonstrated that aggressive treatment strategies could have risks in particular populations.

The ADVANCE trial

The ADVANCE trial also investigated intensive glucose control in people with type 2 diabetes.

Its results showed benefits for certain microvascular outcomes, particularly kidney-related outcomes, without demonstrating an equivalent reduction in major cardiovascular events during the main trial period.

These findings contributed to a more nuanced understanding of glucose targets and treatment safety.

Read the original 2008 ADA Standards of Medical Care.

ADA Diabetes Guidelines 2009: Individualized Glycemic Targets

The 2009 ADA Standards addressed the growing evidence from major glucose-control trials and emphasized that patients differ in their ability to benefit from more intensive treatment.

For many nonpregnant adults, an A1C goal below 7% remained a general recommendation, but goals needed to take individual characteristics into account.

Relevant considerations included:

• Age and expected treatment benefit.
• Duration of diabetes.
• Existing cardiovascular disease.
• History of severe hypoglycemia.
• Other medical conditions.
• Ability to manage complex treatment.
• Individual preferences and circumstances.

Not every patient was expected to pursue the lowest possible A1C result.

The updated 2009 ADA/EASD consensus

Alongside the annual ADA Standards, an updated ADA/EASD consensus algorithm was published in January 2009.

This separate statement reassessed glucose-lowering therapies in light of developing evidence, including the use of newer medication classes and medication safety considerations.

It remained focused primarily on treatment of hyperglycemia in type 2 diabetes.

Original publications:

• ADA Standards of Medical Care in Diabetes — 2009
• ADA/EASD Hyperglycemia Management Consensus — published 2009

What Did the Major Clinical Trials Teach About A1C Targets?

One of the most important lessons of the 2005–2009 period was the distinction between improving glycemic control and assuming that ever-lower glucose targets automatically improve all long-term outcomes.

Clinical trials demonstrated that outcomes could differ by patient population, treatment intensity and duration of follow-up.

The appropriate interpretation is that glucose control remains essential, but its intensity should be personalized. Modern treatment decisions also consider medications' proven cardiovascular and kidney benefits, which extend beyond A1C reduction alone.

Was A1C Used to Diagnose Diabetes Between 2005 and 2009?

Not as an ADA-recommended diagnostic criterion during most of this period.

A1C was well established as a measure of average glycemic exposure and a tool for monitoring diabetes management.

The 2009 ADA Standards discussed the possible future use of A1C for diagnosis, but the diagnostic threshold had not yet been adopted in those annual standards.

An international expert committee recommended an A1C diagnostic threshold of 6.5% in 2009. The ADA subsequently included A1C of at least 6.5% as a diagnostic criterion in its 2010 Standards, using appropriately standardized laboratory testing.

How Diabetes Care From 2005–2009 Differs From Modern Care

Many principles established during this period remain important, including patient education, screening for complications and individualized glycemic management.

However, several major developments changed clinical practice afterward.

• Diagnosis: A1C became an accepted diagnostic test under specified laboratory conditions in 2010.
• Medication selection: Modern treatment can incorporate drug-specific evidence for cardiovascular and kidney outcomes.
• Continuous glucose monitoring: CGM devices, accuracy and integration into care have evolved considerably.
• Obesity management: Additional treatment options and stronger evidence have broadened clinical decision-making.
• Risk-based treatment: Current decisions consider multiple outcomes, not A1C alone.
• Technology: Insulin-delivery systems and glucose-monitoring technology have progressed substantially.

Historical recommendations can explain why certain treatments were common in earlier years, but they should not be used as today's clinical instructions.

Medical information notice: This article is an independently authored historical analysis and is not an official American Diabetes Association or European Association for the Study of Diabetes publication. Historical recommendations are provided for educational purposes only. Diagnosis and treatment should follow current evidence and individualized clinical advice.