The American Diabetes Association (ADA) 2014 guidelines underwent a policy shift to recommend a one-step or two-step approach to gestational diabetes mellitus (GDM) screening. Previously, the ADA had supported the one-step screening method for GDM as revised by the International Diabetes and Pregnancy Study Group (IADPSG) in 2010. The ADA now states that there is insufficient evidence to support the one-step method over the two-step screening method recommended by the National Institutes of Health (NIH) in March 2013. In addition, the new guidelines add a new section on medical nutrition therapy (which was first published in the October 2013 issue of Diabetes Care), further expand the neuropathy section, and consistently emphasize and adhere to evidence-based and patient-centered recommendations. Professor Richard Grant, Chair of the ADA Professional Practice Committee and a scientist in the Research Department at Kaiser Permanente, noted, “In general, as in past years, what we have done this year is to list in order the recommendations that are supported by solid evidence …… We have used as many as possible to We have tried to replace expert advice recommendations with similar recommendations based on high levels of evidence wherever possible. That’s a trend that we’ve been doing this year.” Professor Grant emphasised that there are no significant changes to this year’s guidelines in terms of diabetes management. Other than telling people which type of GDM screening method they need to apply, there are no other particularly big changes in this year’s guidelines. There are no really large studies that have been able to change the direction of diabetes treatment. The new guidelines rely more on evidence-based recommendations for treatment and recognize and emphasize individualized treatment. One-step versus two-step The NIH endorsed the two-step method for the diagnosis of GDM in February 2013, and the American College of Obstetricians and Gynecologists (ACOG) supports the use of this method, which is now commonly used for screening and diagnosis of GDM in clinical practice in the United States. The IADPSG and the World Health Organization support the one-step method, which is more commonly used in Europe and involves a single 75g 2-hour OGTT after fasting. The one-step method can identify more patients with GDM. The IADPSG believes that it is important to identify more patients with GDM, as the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study shows that a mild increase in maternal glucose levels can increase the risk of adverse pregnancy outcomes and adverse neonatal outcomes. However, Professor Grant emphasized that the HAPO study is an observational trial and there is no evidence from randomized clinical trials that one-step or two-step GDM screening improves maternal and neonatal clinical outcomes. However, it is very interesting to note that the IADPSG and NIH guideline writing groups came up with their different recommendations after evaluating and reviewing the same data. And the ADA does not believe it can decide which of these two expert consensus group recommendations is more appropriate. Both recommendations are factually correct and both have judgmental value. More research is urgently needed to further determine which of the two is better for improving maternal and neonatal clinical outcomes. The newly expanded section on diabetic neuropathy provides more detail on the various treatments and their limitations, encouraging physicians to insist that patients take their medications long term to ensure they work, and to use an individualized “trial and error” approach with different drugs and drug combinations. Professor Grant pointed out that neuropathy is a difficult disease to treat, that there is no very good treatment available, and that treatment requires good communication between the care team and the patient. The new section on medical nutrition therapy also emphasizes an individualized approach to treatment, stressing the need to respect overall dietary habits and patient preferences rather than prescribing a specific diet. Lead author Alison Evert, coordinator of the diabetes education program at the University of Washington Medical Center, emphasized, “In fact, the word “diet” is not used in this section. The term ‘diet plan’ or ‘diet’ is used throughout the document, not ‘diet. We want to work with patients to help them achieve individualized health goals. A variety of eating habits can work, and it’s easier for people to stick to the diet plan they’ve been told.” The ADA leads the way In the 2013 ADA guidelines, the big change from the 2012 ADA guidelines is the relaxation of the systolic blood pressure target for antihypertensive therapy in patients with diabetes from less than 130 mm Hg to less than 140 mm Hg in light of evidence that further reductions in systolic blood pressure below 140 mm Hg do not provide additional benefit but rather increase risk. just this week, the 2014 Just this week, the 2014 U.S. Adult Hypertension Guidelines (JNC8) made the same recommendation for patients with diabetes. This latest recommendation was published online December 19, 2013 in the January 2014 supplement of Diabetes Care.