Diabetes Management in Detention Facilities: A Statement of the American Diabetes Association

At any given time, the U.S. criminal justice system contains >2.1 million people in state and federal prisons, local jails, juvenile detention facilities, Indian Country jails, military prisons, immigration detention facilities, and civil commitment centers (1). In addition, many more people pass through the criminal justice system each year. In 2019 alone, >600,000 people were released from state or federal detention authorities to the community (2). It is estimated that 9% of the incarcerated population has diagnosed diabetes (3). The prevalence of diabetes and its related comorbidities and complications will continue to increase in the detained population as the incarcerated population ages and the incidence of diabetes in young people continues to increase (4). Furthermore, the detained population continues to include a disproportionate number of people from minoritized or marginalized ethnic groups (2) who are also disproportionately likely to have diabetes (5).

People with diabetes in detention facilities should receive care that meets national standards, as published in the “Standards of Care in Diabetes” of the American Diabetes Association (ADA), hereafter referred to as Standards of Care (6). Detention facilities have unique circumstances that need to be considered so that standards of care can be achieved (7). Detention facilities should have written policies and procedures for the recognition and management of diabetes and for training of medical and security staff in diabetes care practices. These policies must take into consideration issues such as security needs, transfer from one facility to another, and access to medical personnel, medication supplies, and equipment (diabetes devices to monitor glucose and/or administer insulin). These policies would ensure that detainees have timely access to necessary treatment at all appropriate levels of care. In addition, these policies should encourage and allow people with diabetes to self-manage their diabetes, once assessed and found to be competent in self-management, consistent with security levels. Ultimately, diabetes management is dependent upon having access to needed medical personnel, diagnosis and monitoring equipment, and appropriate medications. Ongoing and reliable diabetes therapy is important to reduce the risk of acute complications, including life-threatening hypoglycemia and hyperglycemia as well as long-term complications, including cardiovascular events, vision loss, renal failure, and amputation. Early identification and intervention for people with diabetes will reduce medical complications requiring transfer out of the facility, which has important implications for security and cost.

This document provides guidance for diabetes care in detention facilities. It is not designed to be a general diabetes management manual. More detailed information on the management of diabetes and related disorders can be found in the ADA Standards of Care, which is updated annually (6). This discussion will focus on areas where the processes for delivery of care to people with diabetes in detention facilities may differ from those in the community, and key points are made at the end of each section. Areas of emphasis, which inform multiple aspects discussed in this document, include 1) timely identification or diagnosis of diabetes treatment needs and continuity of care (at reception/intake, during transfers, and upon discharge), 2) nutrition and physical activity, 3) timely access to diabetes management tools (insulin, blood glucose monitoring [BGM], tracking data, current diabetes management technologies, etc.), and 4) treatment of the whole person with diabetes (self-management education, mental health support, monitoring and addressing long-term complications, specialty care, etc.).

Reception screening is performed for all detainees upon arrival at a detention facility to ensure that emergent and urgent health needs are promptly identified and addressed and to ensure that people with health conditions and those on medications are identified for further assessment and continued treatment.

Reception screening should prioritize safety by identifying people with diabetes who are at a heightened risk for complications, especially those susceptible to hypoglycemia and hyperglycemia as well as hyperglycemic crises such as diabetic ketoacidosis (DKA). This occurs mainly in, but is not limited to, people with diabetes on insulin or other glucose-lowering medications (e.g., sulfonylureas) that may induce hypoglycemia. For these individuals, access to BGM or continuous glucose monitoring (CGM) should be ensured within 1–2 h of their arrival. It is crucial to note that signs of hypoglycemia or hyperglycemia can mimic symptoms of drug or alcohol intoxication or withdrawal. Hence, any person with known or suspected diabetes displaying symptoms of altered mental status, agitation, combativeness, or excessive sweating (diaphoresis) should have their blood glucose levels assessed immediately.

Intake screening entails further information gathering about a person’s health care needs and should occur as soon as possible within 24 h of arrival. Individuals diagnosed with diabetes should promptly undergo a comprehensive medical history review and physical examination by a health care professional (HCP) with prescriptive authority (see Table 4.1 in the Section 4 of Standards of Care, “Comprehensive Medical Evaluation and Assessment of Comorbidities” [8]). If such a professional is not on site, one should be consulted by the screening team. This assessment aims to identify the diabetes type, ongoing treatment plan, risk of diabetes-related emergencies, alcohol consumption, behavioral health concerns, and any diabetes-related complications.

Recognizing if a person has type 1 diabetes is paramount. Insulin omission can lead to severe metabolic decompensation, including DKA. Furthermore, individuals with type 1 diabetes, especially those with hypoglycemia unawareness, are more susceptible to severe hypoglycemia (requiring third-person assistance) and thus need more regular glucose monitoring. Until a qualified HCP confirms otherwise, any individual on insulin should be presumed to have type 1 diabetes. The assessment should revisit past treatment plans, glycemic management, and complication history.

Upon entering the detention system, it is vital to ensure continuity in medication and nutritional plans to prevent severe hypoglycemia or hyperglycemia, which can quickly escalate to irreversible complications or even death.

Moreover, individuals using diabetes technology devices (CGM, automated insulin delivery systems, and insulin pumps) should retain uninterrupted access to these tools upon their introduction to the detention system unless an individualized case-by-case assessment shows that doing so would pose a safety or security risk.

All potential elements of the initial medical evaluation are included in Table 4.1 of the Standards of Care (8). The essential components of the initial history and physical examination are detailed in Table 1 here. Referrals should be made immediately if the person with diabetes is pregnant.

• Individuals with a diagnosis of diabetes should have a complete medical history and undergo a comprehensive intake physical examination in a timely manner, completed by a qualified HCP with appropriate experience and training in diabetes care and management (see Standards of Care Table 4.1 [8]).

• Particular attention should be paid to neurovascular examinations of skin integrity, sensory function, and pedal pulses.

• Individuals treated with insulin or sulfonylureas should have a BGM determination within 1–2 h of arrival.

• Medications and nutritional goals should be continued without interruption upon entry into the detention setting.

• Existing use of diabetes devices should be continued without interruption upon entry into detention setting.

Consistent with the ADA Standards of Care, all individuals should be evaluated for diabetes risk factors at the intake physical and at appropriate times thereafter. Those who are at high risk should be considered for screening. If pregnant, a risk assessment for gestational diabetes mellitus should be undertaken at the first prenatal visit. For more detailed information on screening for both type 2 and gestational diabetes mellitus, see Section 15 of the Standards of Care (9).

Individualized glycemic goals are fundamental to diabetes care plans. A management plan to achieve appropriate customized glycemic goals should be developed at the time of initial medical evaluation (10). For most people with diabetes, an A1C goal of ≤7% may be appropriate, but goals should be individualized (10), and less stringent treatment goals may be appropriate for people with diabetes with a history of severe hypoglycemia, people with limited life expectancies, the elderly, and individuals with certain comorbid conditions (9–14). This plan should be documented in the person’s record and communicated to all people involved in the person’s care.

People with diabetes should receive medical care from an HCP-coordinated team. Such teams include, but are not limited to, physicians, nurse practitioners, physician associate/physician assistants, nurses, registered dietitian nutritionists, clinical pharmacists, and mental health professionals with expertise in diabetes (15). Diabetes self-management education is an integral component of care, and individuals with diabetes should play an active role in their own treatment (16). In promoting the performance of diabetes self-management in a detention setting, the treatment time should assess and accommodate the needs of the person with diabetes, including their individualized circumstances in the detention setting. If possible, the person with diabetes should be permitted to continue all or parts of their self-management plan under supervision.

For people with diabetes, diabetes care medical visits should be scheduled based on the care needs of the person with diabetes (e.g., those who did not achieve treatment goals or have new medical assessment or treatment needs may need more frequent visits).

It may be helpful to house people with diabetes who are treated with insulin in a common unit, if this is possible, safe, and consistent with providing access to programs at the detention facility that would otherwise be available to them. Use of such a unit should not result in any person with diabetes being held in a more restrictive setting than would otherwise be appropriate. Common housing not only can facilitate mealtimes and medication administration but also provides an opportunity for diabetes self-management education to be reinforced by fellow people with diabetes.

It is important to support people with diabetes to engage in health-promoting behaviors (preventive, treatment, and maintenance), including glucose monitoring, administering insulin and medications, using diabetes technologies, engaging in physical activity, and making nutritional changes. Evidence supports using a variety of behavioral strategies and multicomponent interventions to help people with diabetes develop health behavior routines, including motivational interviewing, individual activation, goal setting and action planning, problem-solving, tracking or self-monitoring health behaviors, and facilitating opportunities for social support (17). These components should be considered in designing and implementing a diabetes management plan for each person with diabetes in detention.

Clinically significant mental health diagnoses are considerably more prevalent in people with diabetes than in those without. Emotional well-being is an important part of diabetes care and self-management. Psychological and social challenges can impair the individual’s ability to carry out diabetes care tasks and potentially compromise health status. Therefore, psychological symptoms, both clinical and subclinical, must be addressed.

Psychosocial/mental health assessment and treatment should be incorporated into the routine care of people with diabetes in detention rather than waiting for a specific problem or deterioration in metabolic or mental health status to occur (16).

Facilities should institute nutritionally balanced menus that are safe and appropriate for people with diabetes, its complications, and associated comorbidities, such as heart and kidney disease. The nutritional plan in the detention setting should, to the extent possible, have consistent carbohydrate content at each meal and means to identify the carbohydrate, protein, and fat content of each food selection and meal. Providing the content of food selections and/or providing education in assessing content enables people with diabetes to meet the requirements of their individual nutritional goals.

Nutrition counseling and menu planning is a cornerstone of the multidisciplinary approach to diabetes management in detention facilities. Combining education, interdisciplinary communication, and food intake monitoring aids detainees in comprehending their nutritional necessities, optimizing diabetes management both during and after incarceration.

Nutritional counseling is vital for diabetes self-management. Individuals should receive tailored nutritional guidance, ideally from a registered dietitian nutritionist experienced in diabetes care (16).

Educating the person with diabetes, individually or in a group setting, about how food choices directly affect glycemia is the first step in facilitating self-management. This education enables the person with diabetes to identify food choices that match their nutrition plan from those available in the dining hall and commissary. Such an approach is more realistic in a facility where the person with diabetes can make food choices. Even if food choice selections are not an option, people with diabetes should still have the option to not consume all the food offered on their tray and to limit their portions. People with diabetes should also be allowed to replace carbohydrates with a noncarbohydrate option.

For those on insulin or hypoglycemia-inducing oral agents, the availability of snacks, especially those containing fast-acting carbohydrates, is essential to avoid and treat hypoglycemia. These snacks should be prescribed and readily available. Commissary staff should be educated in appropriate specific treatments for hypoglycemia, such as 4 oz juice or 8 oz skim milk. Ensuring uninterrupted commissary access is vital, as swift intake of fast-acting carbohydrates can avert severe consequences like seizures or coma. Commissaries should also contribute to nutritional management by offering healthier options and disclosing the macronutrient content of items.

Meal and snack timings should be coordinated with medication schedules to reduce hypoglycemia risks. This coordination is crucial for those on rapid-acting premeal insulin. Glucose testing and insulin dosing should occur within 15 min before a meal. If such coordination is not possible, an alternative strategy to reduce hypoglycemia risks should be established in collaboration with a knowledgeable health care professional. For comprehensive information, refer to the ADA consensus report “Nutrition Therapy for Adults With Diabetes or Prediabetes” (18).

People with diabetes must have access to prompt treatment for hypoglycemia and hyperglycemia. Facility staff should be trained in the recognition and treatment of hypoglycemia and hyperglycemia, and appropriate staff should be trained to administer glucagon. After such emergency care, people with diabetes should be referred for appropriate medical care to minimize the risk of future decompensation.

Institutions should implement a policy requiring staff to notify the covering HCP (physician, nurse practitioner, or physician associate/physician assistant) of all glucose results outside a specified range, as determined by the treating physician (e.g., <70 or <54 mg/dL and >250 mg/dL for hypoglycemia and hyperglycemia, respectively).

Severe hyperglycemia in a person with diabetes may be the result of intercurrent illness, missed or inadequate medication, or oral or intravenous corticosteroid therapy. Detention facilities should have systems in place to identify and refer to medical staff all people with diabetes with consistently elevated blood glucose, particularly in the setting of intercurrent illness.

The stress of illness in those with diabetes frequently aggravates glycemic management and necessitates more frequent monitoring of blood glucose (e.g., every 4–6 h for people with type 1 diabetes) (10). Marked hyperglycemia requires temporary adjustment of the treatment plan and, if accompanied by ketosis, assessment by the diabetes clinical care team. Adequate fluid and caloric intake must be ensured. Nausea or vomiting possibly associated with hyperglycemia may indicate DKA, a life-threatening condition that requires immediate medical care to prevent complications and death. Detention facilities should identify individuals with type 1 and 2 diabetes who are at risk for DKA, particularly those with a prior history of frequent episodes of DKA. For further information, see “Hyperglycemic Crises in Adult Patients With Diabetes” (19). Any person with insulin-treated diabetes who becomes ill, runs a fever, or complains of abdominal pain, nausea, or vomiting or other unusual symptoms should be tested for ketonuria or ketonemia, regardless of the blood glucose level. It is important to note that people with type 2 diabetes who are treated with sodium–glucose cotransporter 2 inhibitors (SGLT2i) (e.g., dapagliflozin, bexagliflozin, canagliflozin, empagliflozin, and ertugliflozin) may develop DKA with normal or minimally elevated glucose levels (20).

Level 1 hypoglycemia is defined as a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L). Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL [3.0 mmol/L]) is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event (10).

Level 3 severe hypoglycemia is a medical emergency defined as hypoglycemia requiring assistance of a third party and is often associated with mental status changes that may include confusion, incoherence, combativeness, somnolence, lethargy, seizures, or coma (10). Signs and symptoms of severe hypoglycemia can be confused with intoxication, drug withdrawal, or behavioral “acting out.” Individuals with diabetes exhibiting signs and symptoms consistent with hypoglycemia, particularly altered mental status, agitation, and diaphoresis, should have their glucose levels checked immediately.

Security staff who supervise individuals at risk for hypoglycemia (i.e., those on insulin, sulfonylureas, or glinides) should be educated in the emergency response protocol for recognition and treatment of hypoglycemia. Whenever possible, low blood glucose should be documented by BGM. In people with diabetes who are alert and conscious, hypoglycemia can generally be self-treated by the individual with oral carbohydrates, such as glucose tablets, fruit juice, or other glucose-containing foods, and at-risk individuals need to have ready access to these items (10). Staff members should also have ready access to glucose tablets or equivalent. In general, 15–20 g oral glucose will be adequate to treat hypoglycemic events. BGM and treatment should be repeated at 15-min intervals until blood glucose levels return to normal (>70 mg/dL [3.9 mmol/L]).

Staff should have glucagon, for intramuscular or subcutaneous injection or intranasal spray, available to treat severe hypoglycemia. Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia require reevaluation of the diabetes management plan by the medical staff (10). In certain cases of unexplained or recurrent severe hypoglycemia, it may be appropriate to admit the individual to the medical unit for observation and reassessment of diabetes care plans.

Detention facilities should have systems in place to identify the individuals at greater risk for hypoglycemia (those on glucose-lowering medications that may cause hypoglycemia, e.g., insulin or sulfonylurea therapy) and to ensure prevention, early detection, and treatment of hypoglycemia. If possible, individuals at greater risk of severe hypoglycemia (e.g., those with a prior episode of severe hypoglycemia) may be housed in units closer to the medical unit to minimize delays in treatment.

Those on CGM, automated insulin delivery systems, and/or insulin pumps should be allowed to continue to use diabetes technology, based on a case-by-case assessment of security and other considerations in allowing someone in detention to retain an assistive device. CGMs, automated insulin delivery systems, and insulin pumps require supplies (e.g., glucose sensor, infusion set, and insulin cartridge) that must be replaced on a regular schedule and provided on an as-needed basis. A CGM can be an important tool to proactively prevent severe hypoglycemia episodes (21).

• Train facility staff in the recognition, treatment, and appropriate referral for hypoglycemia and hyperglycemia.

• Train appropriate staff to administer glucagon.

• Train staff to recognize symptoms and signs of serious metabolic decompensation and immediately refer the individual for appropriate medical care.

• Develop and implement a policy requiring staff to notify a physician of all glucose results outside a specified range, as determined by the treating physician.

• Identify people with diabetes who are at high risk for DKA.

• Urine ketones should be measured in people with diabetes and persistent hyperglycemia (blood glucose >300 mg/dL for 24 h). Presence of moderate or large urinary ketones requires urgent medical evaluation and treatment.

Medications for diabetes should be initiated and adjusted by HCPs with expertise in diabetes management. Treatment plans depend on the diagnostic classification and the affected person’s needs (22). Formularies should provide access to usual and customary oral and injectable medications, including insulin, that are necessary to treat diabetes. Procedures must be in place to obtain an individual’s diabetes medications immediately upon entry into the facility. People with diabetes at all levels of custody should have access to medication at dosing frequencies that are consistent with their treatment plan and medical direction. If feasible and consistent with security concerns, people on multiple doses of short-acting oral medications should be placed in a “keep on person” program.

All people with type 1 diabetes require daily treatment with insulin and glucose monitoring to adjust insulin dosing. People with type 1 diabetes should be treated with a daily injection of long-acting basal insulin plus rapid-acting prandial insulin at mealtimes (20). Alternatively, rapid-acting insulin can also be administered via insulin pumps or automated insulin delivery systems, and monitoring occurs by CGM in an appropriate security setting. The dose of premeal insulin should be varied based on meal content (mostly based on insulin-to-carbohydrate ratio) and blood glucose levels (also called correction factor). However, sole reliance on “sliding scale” insulin (i.e., correction or supplemental insulin without basal insulin) is inappropriate and can lead to dangerous hypoglycemia or hyperglycemia. Telehealth consultations may be appropriate when treatment by a diabetes specialist (endocrinologist, physician with training or expertise in diabetes, physician associate/physician assistant, nurse practitioner, or certified diabetes care and education specialist) is needed (15).

Selection of medications for treatment of people with type 2 diabetes should be in accordance with the current ADA Standards of Care (see Fig. 9.3 in Section 9, “Pharmacologic Approaches to Glycemic Treatment” [20]) based on an individualized approach to a person’s needs and risks (15). In addition, the use of medications with low potential for hypoglycemia (biguanides, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonist, and SGLT2i) is recommended given the limited access to glucose monitoring in many settings. Some people with type 2 diabetes will require insulin treatment, alone or in combination with other glucose-lowering medications.

For insulin therapy (type 1 and type 2 diabetes), at a minimum, a long-acting basal insulin and a rapid-acting prandial insulin (e.g., aspart, lispro, or glulisine) should be available on the institution’s formulary. The timing of prandial insulin injections is critically important and should be immediately before the meal or no later than 10 min after a meal. Basal insulin should be administered at the same time each day. Reliance on insulin sliding scales is ineffective and potentially dangerous, and it is strongly discouraged (15). A much-preferred plan is periodic review of glucose monitoring results, with proactive adjustment of standing insulin doses. The safe use of any insulin plan requires daily glucose monitoring per a person’s individualized monitoring plan. If available, a CGM is a helpful tool for individuals on multiple daily insulin injections (23).

Concentrated insulin must be administered via U.S. Food and Drug Administration–approved insulin pens, as the use of syringes may lead to dosing error.

People treated with insulin should be permitted to self-inject when consistent with security needs. Medical department nurses should determine whether individuals have the necessary skill and responsible behavior to be allowed self-administration and the degree of supervision necessary. When needed, this skill should be a part of a person’s education. Disposable single-use syringe systems should be established.

• The sole use of sliding-scale insulin is strongly discouraged.

• Formularies should provide access to usual and customary oral and injectable medications, including insulins to treat diabetes and related conditions.

• Individuals should have access to continuous subcutaneous insulin infusion (insulin pump therapy) and CGM if they were using these modalities before incarceration or are deemed eligible for their use, unless there is a specific safety or security risk identified based on an assessment of the individual and circumstances.

• Individuals should have access to medication at dosing frequencies that are consistent with their treatment plan and medical direction.

• Detention facilities should implement policies and procedures to diminish the risk of, and treat episodes of, hypoglycemia and hyperglycemia during off-site travel (e.g., court appearances).

Insulin pump therapy should be considered as an option for all detained adults and youth with type 1 diabetes who can safely manage the device and with appropriate medical supervision (23).

A CGM can be an important tool to monitor glucose levels and to proactively prevent severe hypoglycemia episodes (21).

Insulin pumps, automated insulin delivery systems, and CGM are effective means of implementing intensive diabetes management with the goal of achieving near-normal levels of glucose (24). While the use of these modalities may be difficult in detention facilities, every effort should be made to continue the use of insulin pumps, automated insulin delivery systems, and CGM in people who were using these therapies before incarceration or to institute these therapies if clinically indicated to achieve glucose goals. Facilities should use an individualized case-by-case assessment of security and other considerations in allowing someone in detention to retain these devices, similar to other assistive devices that are permitted to those with medical or disability needs (e.g., continuous positive airway pressure machine, glasses, or a cane or walker). Care should be taken to ensure that these devices are used appropriately pursuant to a diabetes management plan and (as with insulin administration syringes) ensure adequate supervision of use of needles.

Many detention facilities have HCPs providing diabetes care who do not have primary care or diabetes care training. When an HCP is unable to assist the person with diabetes attain their diabetes goals after multiple clinic visits or when an HCP feels unable to manage the individual’s diabetes, the detention facility should have a mechanism to refer the person with diabetes to an HCP with expertise in diabetes either in person or via telehealth.

Practices for referral to other specialists should follow recommendations of the ADA’s Standards of Care and clinical judgment in case of other medical needs.

Advances in diabetes technology have facilitated individual care and education via telehealth in the general diabetes population and, more recently, in the detention setting (25–27). If available, CGM, automated insulin delivery systems, and newer insulin pumps can send data securely over the internet. Diabetes HCPs, including physicians, nurse practitioners, physician associates/physician assistants, registered dietitians, educators, podiatrists, clinical pharmacists, and others, can fulfill many of the educational and health care needs of the incarcerated population via web-based communication (15). Routine follow-up via telemedicine has been shown to improve glycemic outcomes and can replace most one-on-one visits for diabetes education and management.

All people with a diagnosis of diabetes should receive routine screening for diabetes-related complications, as detailed in the ADA Standards of Care (8). Interval chronic disease clinics for people with diabetes provide an efficient mechanism to monitor individuals for complications of diabetes. In this way, appropriate referrals to consultant specialists, such as optometrists and ophthalmologists, nephrologists, podiatrists, and cardiologists, can be made on an as-needed basis and interval laboratory testing can be done.

A comprehensive foot evaluation should be performed annually to identify ulcer and amputation risk factors, including skin inspection, foot deformity assessment, neurological evaluation (using 10-g monofilament testing plus another method, such as pinprick), and vascular assessment (28). Individuals with sensory loss or a history of ulceration or amputation should have their feet checked at every visit and provide details about any prior foot issues, smoking habits, and symptoms of neuropathy and vascular disease. Initial peripheral arterial disease screening should evaluate lower-extremity pulses and other related symptoms. Those with symptoms or decreased pulses should undergo further vascular assessment. A team-based approach is essential for those with foot ulcers or high-risk feet. People with diabetes who smoke, have a history of foot complications, or show signs of peripheral arterial disease should be referred to foot care specialists. Everyone with diabetes should receive foot self-care education, and those at high risk should consider specialized footwear. People with diabetes and a foot ulcer or impending foot ulcer should be off-loaded (i.e., provided therapeutic shoes designed to provide pressure redistribution). In a detention setting, this means that the individual needs protected housing in an infirmary or similarly protected housing so that the need for them to walk is minimized.

People with a history of amputation are at particular risk for the development of new lesions and further amputation. Special shoes should be provided, as recommended by qualified HCPs, to aid healing of foot lesions and to prevent the development of new lesions. Choosing shoes for the at-risk population without active lesions should take into consideration the risk of excessive friction causing blisters, callus, or fresh ulceration. For example, heavy work boots that may be appropriate for the general detention facility population may cause pressure- and friction-related lesions that can lead to infection and amputation.

People with type 2 diabetes should be screened for diabetic retinopathy by a comprehensive dilated eye examination at the time of their diabetes diagnosis, while those with type 1 diabetes should be screened within 5 years of diagnosis (28). The exam should be conducted by an ophthalmologist or optometrist. If annual exams show no evidence of retinopathy and blood glucose levels are at goal, screenings can be done every 1–2 years. However, if any level of diabetic retinopathy is detected, yearly examinations are essential, and more frequent exams are needed if retinopathy progresses or poses a threat to vision. Using retinal photography with remote reading or validated assessment tools can be an effective screening method for diabetic retinopathy, provided there are clear referral pathways for comprehensive eye exams when necessary.

Annually, both urinary albumin, examined by methods such as the spot urinary albumin-to-creatinine ratio test, and estimated glomerular filtration rate (eGFR) should be evaluated in individuals with type 1 diabetes duration ≥5 years and in everyone with type 2 diabetes (28). For those with confirmed diabetic kidney disease, these tests should be conducted 1–4 times yearly based on disease progression. To reduce or slow the progression of chronic kidney disease in people with diabetes, it is essential to optimize glucose and blood pressure management. For those with hypertension and elevated urinary albumin, ACE inhibitors or angiotensin receptor blockers are recommended. For people with type 2 diabetes with diabetic kidney disease, appropriate agents (e.g., SGLT2i) are recommended to reduce kidney disease progression and cardiovascular risks. A nonsteroidal mineralocorticoid receptor agonist such as spironolactone is also part of guideline-directed therapy. A decrease in urinary albumin is recommended for slowing kidney disease progression. Referral to a nephrologist is recommended for increasing urinary albumin levels, decreasing eGFR, or when the managing HCP is facing uncertainties in disease etiology and management (14).

People with type 2 diabetes are at a particularly high risk for cardiovascular disease (CVD), including coronary artery disease (CAD) and stroke. CVD risk factor management is of demonstrated benefit in reducing this complication in people with diabetes (12).

Routine screening for CAD in asymptomatic individuals is not advised if atherosclerotic cardiovascular disease (ASCVD) risk factors are managed, due to a lack of evidence showing improved outcomes. However, screening for CAD should be considered in the presence of atypical cardiac symptoms, signs of associated vascular disease (e.g., carotid bruits, transient ischemic attacks, stroke, claudication, or peripheral arterial disease [PAD]), or electrocardiogram abnormalities. Adults with diabetes, at higher risk for cardiac abnormalities and heart failure, may benefit from natriuretic peptide measurement (BNP or NT-proBNP) to prevent progression to symptomatic heart failure. For those with abnormal peptide levels, echocardiography is recommended to detect stage B heart failure. People with diabetes who are asymptomatic and aged ≥50 years with microvascular disease, foot complications, or any end-organ damage from diabetes should undergo PAD screening using the ankle-brachial index to inform CVD prevention and limb preservation strategies. Screening for PAD is also advised for those with a diabetes duration of ≥10 years (12).

At every routine diabetes clinical visit, blood pressure should be measured. Hypertension is identified when the systolic blood pressure is ≥130 mmHg or diastolic is ≥80 mmHg, based on an average of multiple measurements from separate occasions. If elevated levels are detected in the range of systolic 120–129 mmHg and diastolic <80 mmHg, then multiple readings (including those on different days) are required to confirm hypertension. Individuals with a blood pressure of ≥180/110 mmHg combined with CVD can be diagnosed with hypertension after just one reading. For individuals with diabetes and hypertension, blood pressure goals should be tailored based on cardiovascular risk, potential side effects of medications, and the person’s preferences, established through mutual decision-making. If their blood pressure remains consistently ≥130/80 mmHg, they should be considered for antihypertensive medication with an aim to maintain a goal blood pressure of <130/80 mmHg, provided it is safe to achieve.

People with diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of atherosclerotic heart disease (12). Lipid abnormalities should be managed using lifestyle management and pharmacotherapy. Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or a change in dose, and annually thereafter to monitor the response to therapy and inform medication adherence.

For individuals with diabetes, aspirin therapy (75–162 mg/day) is advised for those with a history of atherosclerotic CVD (12). If there is a documented aspirin allergy, clopidogrel (75 mg/day) is recommended. Aspirin can also be considered for primary prevention in people with diabetes at high cardiovascular risk only after discussing its benefits versus bleeding risks.

Individualized lipid monitoring and therapy adjustments are critical. For adults not on lipid-lowering treatments, obtaining a lipid profile at diagnosis, initially, annually, or more often based on clinical judgment is recommended. Upon initiating or modifying statin or lipid-lowering treatments, lipid profiles should be evaluated at the start, 4–12 weeks after adjustments, and yearly to assess treatment effectiveness (12).

Moderate-intensity statin therapy is advised for those aged 40–75 years with diabetes but no ASCVD, alongside lifestyle changes. For younger adults (aged 20–39 years) with additional ASCVD risk factors, starting statin therapy is considered beneficial. High-intensity statin therapy is recommended for individuals aged 40–75 years at elevated cardiovascular risk to achieve a ≥50% LDL cholesterol reduction, with a target of <70 mg/dL. For those not meeting LDL targets on maximum tolerated statins, adding ezetimibe or PCSK9 inhibitors is suggested (12).

For individuals aged <75 years on statins, continuing therapy is prudent, and starting moderate-intensity statins may be considered after evaluating benefits and risks. For statin-intolerant individuals, bempedoic acid is an alternative for reduction of cardiovascular risk. Statin use is contraindicated in pregnancy (12).

In secondary prevention for those with diabetes and ASCVD, treatments with high-intensity statins plus lifestyle modifications aim for a ≥50% LDL reduction, with an LDL goal of <55 mg/dL. If goals are unmet, adding ezetimibe or PCSK9 inhibitors is advised. For statin intolerance, the maximum tolerated dose or alternatives like PCSK9 inhibitors or bempedoic acid are recommended (12).

In managing hypertriglyceridemia, a tailored approach is essential. For severe hypertriglyceridemia (fasting levels ≥500 mg/dL), identifying secondary causes and considering medical therapy to prevent pancreatitis is crucial. For moderate levels (175–499 mg/dL), addressing lifestyle and secondary factors like obesity, diabetes, and other diseases, as well as medication effects, is recommended. Additionally, for those with controlled LDL cholesterol on statins but with elevated triglycerides (135–499 mg/dL) and additional cardiovascular risk factors, adding icosapent ethyl can reduce cardiovascular risk. This approach highlights the need for personalized treatment plans based on triglyceride levels and cardiovascular risk profiles. Combining statins with fibrates or niacin does not improve cardiovascular outcomes and is not recommended due to a lack of benefit and potential for increased side effects, including stroke risk (12).

Consider use of an SGLT2i or glucagon-like peptide 1 receptor agonist for individuals with CVD or multiple cardiovascular risk factors. Consider SGLT2i for individuals with congestive heart failure (12).

People with type 1 diabetes should be screened for autoimmune thyroid disease soon after diagnosis and periodically thereafter (8).

BGM allows caregivers and people with diabetes to evaluate diabetes management plans. The frequency of monitoring will vary by a person’s glycemic management and diabetes plans (10). People with type 1 diabetes are at risk for hypoglycemia and should have BGM performed three or more times daily or have access to CGM technology. Glucose should be monitored prior to meals, at bedtime, prior to physical activity, when low blood glucose is suspected, and after treating low blood glucose. People with type 2 diabetes on insulin should be monitored at least once daily and more frequently based on their management plan. People treated with oral agents should have BGM performed with sufficient frequency to facilitate the goals of glycemic management, assuming that there is a program for ongoing medical review of these data to drive changes in medications. Those whose diabetes has not met glycemic goals or whose therapy is changing should have more frequent monitoring. Unexplained hyperglycemia in a person with diabetes suggests impending illness, DKA, or nonketotic hyperglycemic hyperosmolar state; the person should be evaluated by an HCP, and urine ketone testing should be performed. (See “Urgent and Emergency Issues,” above.)

Glycated hemoglobin (A1C) is a measure of long-term (2- to 3-month) glycemic management (10). Perform the A1C test at least two times a year in people who are meeting treatment goals (and who have stable glycemic management) and quarterly in people whose therapy has changed or who are not meeting glycemic goals. Discrepancies between glucose monitoring results and A1C may indicate further need for evaluation.

In the detention setting, policies and procedures need to be developed and implemented regarding BGM that address the following:

• Infection control, including single-use lancing devices

• Education of staff and people with diabetes

• Proper choice of glucose meter

• Disposal of testing lancets

• Quality control programs

• Access to health services

• Size adequacy of the blood sample

• Individual performance skills

• Documentation and interpretation of test results

• Availability of test results for the health care provider

• In the detention setting, policies and procedures need to be developed and implemented to enable monitoring of blood glucose to occur at the frequency necessitated by the individual’s glycemic management and diabetes plan.

• A1C should be checked every 3–6 months.

Self-management education is the cornerstone of treatment for all people with diabetes. The HCP must advocate for individuals to participate in self-management as much as possible. Individuals with diabetes who learn self-management skills and make lifestyle changes can more effectively manage their diabetes and avoid or delay complications associated with diabetes. This premise has been demonstrated in the detention setting (29). In the development of a diabetes self-management education program in the detention setting, the unique circumstances of the person should be considered while still providing, to the greatest extent possible, the elements of the “2022 National Standards for Diabetes Self-Management Education and Support” (29). A staged approach can be used depending on the needs assessment and the length of incarceration. Table 2 sets out the major components of diabetes self-management education. Core diabetes self-care management skills should be addressed as soon as possible; other aspects of education can be provided as part of an ongoing education program.

Self-management education should be, where possible, coordinated by a diabetes care and education specialist who works with the facility to develop policies, procedures, and protocols to ensure that nationally recognized education guidelines are implemented. The educator also can identify individuals who need diabetes self-management education, including an assessment of the individuals’ medical, social, and diabetes histories; diabetes knowledge, skills, and behaviors; and readiness to change.

Policies and procedures should be implemented to ensure that the health care staff has adequate knowledge and skills to direct the management and education of people with diabetes. The health care staff needs to be involved in the development of the custody staff’s training program. The staff education program should be at a lay level. What training includes and who conducts the training may vary because of the different locations of detention settings. However, training should be offered at least biannually, and the curriculum should cover the following:

• What diabetes is

• Signs and symptoms of diabetes

• Risk factors

• Signs and symptoms of, and emergency response to, hypoglycemia and hyperglycemia

• Glucose monitoring

• Medications

• Physical activity

• Nutrition issues, including timing of meals and access to snacks

• Include diabetes in custodial or security staff education programs.

People with diabetes who are withdrawing from drugs and alcohol need special consideration. Alcohol, tobacco, opioids, cocaine, amphetamine, psychostimulants, and other drugs of abuse can have complex interactions with glucose regulation (16,30). This issue particularly affects initial police custody and jails. At an intake facility, proper initial identification and assessment of these people is critical, and a careful history of chronic or recent exposure to drugs should be obtained. The presence of diabetes may complicate detoxification. People with diabetes in need of complicated detoxification should be referred to a facility equipped to deal with high-risk detoxification. People with diabetes should be educated in the risks involved with smoking, vaping, and other tobacco products. All inmates should be advised not to smoke, vape, or use other tobacco products. Assistance in cessation should be provided as practical.

Cannabis use is prevalent in the U.S. Assessment and awareness that cannabis use is associated with cyclic vomiting syndrome and risk for DKA is critical in detention settings (31–33). The risk remains elevated even after cessation of cannabis use (31,34).

Individuals may be housed in jails for a short period of time before being transferred or released. It is not unusual for individuals in a prison or other detention system to be transferred within the system several times during their incarceration. One of the many challenges that HCPs face when working in the detention system is how to best collect and communicate important health care information in a timely manner when a person is in initial police custody, is detained for a short period, or is transferred from one facility to another. The importance of this communication is critical when the person has a chronic illness such as diabetes, as a delayed or missed dose of insulin or meal can have serious consequences.

Transferring a person with diabetes from one detention facility to another requires a coordinated effort. To facilitate a thorough review of medical information and completion of a transfer summary, it is critical for custody personnel to provide the health care team with sufficient notice before the movement of that individual.

Before the transfer, the health care staff should review the individual’s medical record and complete a medical transfer summary that includes the individual’s current health care issues. At a minimum, the summary should include the following:

• The individual’s diagnosis

• The individual’s current medication plan and dosages

• The date and time of the last medication administration

• Any recent monitoring results (e.g., BGM and A1C)

• Other factors that indicate a need for immediate treatment or management at the receiving facility (e.g., recent episodes of hypoglycemia, history of severe hypoglycemia or frequent DKA, concurrent illnesses, or presence of diabetes complications)

• Information on scheduled treatment/appointment if the receiving facility is responsible for transporting the individual to that appointment

• Name, telephone and fax number, and e-mail, if available, of a contact person at the transferring facility who can provide additional information, if needed

• Name, telephone and fax number, and e-mail, if available, of the person’s primary care physician or endocrinologist who was managing their diabetes prior to incarceration, if available

The medical transfer summary, which acts as a quick medical reference for the receiving facility, should be transferred along with the individual. To supplement the flow of information and to increase the probability that medications are correctly identified at the receiving institution, sending institutions are encouraged to provide each individual with a medication card to be carried by the individual that contains information concerning diagnoses, medication names, dosages, and frequency. Diabetes supplies, including diabetes medication, should accompany the individual.

The sending facility must be mindful of the transfer time to provide the individual with medication and food if needed. The transfer summary or medical record should be reviewed by a health care provider upon arrival at the receiving institution.

Planning for someone’s discharge from detention settings should include instruction in the long-term complications of diabetes, the necessary lifestyle changes and examinations required to prevent these complications, and, if possible, where someone can obtain regular follow-up medical care. A quarterly meeting to educate people with upcoming discharges about community resources can be valuable. Inviting community agencies to speak at these meetings and/or provide written materials can help strengthen the community link for individuals discharging from detention facilities.

Discharge planning for people with diabetes should begin at least 1 month before discharge. During this time, applications for appropriate entitlements should be initiated. Any gaps in the individual’s knowledge of diabetes care need to be identified and addressed. The detention facility’s discharge planning team should provide the individual a list of community resources and assist in securing an appointment for follow-up care with a community provider. A supply of medication and diabetes-related supplies adequate to last until the first medical appointment after release should be provided to the individual upon release. The individual should be provided with a written summary of their current health care issues, including medications and doses, recent A1C values, etc.

It is essential that the transport of people from jails, prisons, or other detention settings to off-site appointments, such as medical visits or court appearances, does not cause significant disruption in the timing of insulin, medications, and meals. Detention facilities and police lockups (i.e., local temporary holding facilities) should implement policies and procedures to diminish the risk of hypoglycemia and hyperglycemia by, for example, providing carry-along meals and medications for individuals traveling to off-site appointments or changing the insulin plan for that day. The availability of prefilled insulin pens provides an alternative for off-site insulin delivery. Steps should be taken to ensure that parents have access to necessary diabetes management throughout the transport process, including contingency supplies (e.g., transport with a BGM in case a CGM sensor fails as well as a backup insulin delivery method).

• For all interinstitutional transfers, complete a medical transfer summary to be transferred with the individual.

• Diabetes supplies and medication should accompany the individual during transfer.

• Begin discharge planning with adequate lead time to ensure continuity of care and facilitate entry into community diabetes care.

Practical considerations may prohibit obtaining medical records from HCPs who treated the individual before arrest. Intake facilities should implement policies that 1) define the circumstances under which prior medical records are obtained (e.g., for individual who have an extensive history of treatment for complications), 2) identify the individual(s) responsible for contacting the prior HCPs, and 3) establish procedures for tracking requests.

Facilities that use outside medical professionals should implement policies and procedures for ensuring that key information (e.g., test results, diagnoses, HCP orders, and appointment dates) is received from the HCPs and incorporated into the individual’s health record after each outside appointment. The procedure should include, at a minimum, a means to highlight when key information has not been received and the designation of a person responsible for contacting the outside provider for this information. All health records should contain BGM test results in a specified, readily accessible section and should be reviewed on a regular basis.

Children and adolescents with diabetes, particularly type 1 diabetes, present special considerations in disease management, even outside the setting of a detention facility (35). Children and adolescents with diabetes should have initial and follow-up care with HCPs who are experienced in their care (35). Confinement increases the difficulty in managing diabetes in children and adolescents, as it does for adults. Detention facility authorities also have different legal obligations for children and adolescents.

Growing children and adolescents have greater caloric/nutritional needs than adults. In youth with type 1 diabetes, insulin dosing based on carbohydrate amounts is of particular importance (16). The provision of adequate calories and nutrients appropriate for children and adolescents is critical to maintaining healthy growth and development (35,36). Physical activity should be provided at the same time each day (16,35,37). If increased physical activity occurs, additional BGM is necessary and additional carbohydrate snacks may be required to avoid or respond to hypoglycemia (16,35).

Children and adolescents who are incarcerated for extended periods should have follow-up visits at least every 3 months with HCPs who are experienced in the care of children and adolescents with diabetes (35). Thyroid function tests and fasting lipid and microalbumin measurements should be performed according to recognized standards for children and adolescents (35) to monitor for autoimmune thyroid disease and complications and comorbidities of diabetes.

Children and adolescents with diabetes exhibiting unusual behavior should have their blood glucose checked at that time. Because children and adolescents are reported to have higher rates of nocturnal hypoglycemia (35,38), consideration should be given to the use of episodic overnight BGM in these individuals. In particular, this should be considered in children and adolescents who have recently had their basal/bolus insulin dose changed.

A risk assessment for gestational diabetes mellitus should be undertaken at the first prenatal visit and when clinically indicated. Pregnancy in a person with diabetes is, by definition, a high-risk pregnancy. Every effort should be made to ensure that treatment of the pregnant person with diabetes meets accepted standards (9,39). It should be noted that, in the setting of pregnancy, glycemic standards are more stringent, the details of dietary management are more complex and exacting, insulin use is the standard of care, and several medications used in the management of diabetic comorbidities are known to increase the risk for birth defects and must be discontinued. Pre- and postpartum care should follow standards as outlined by the ADA Standards of Care.

People with diabetes should receive care that meets national standards. Being incarcerated does not change these standards. People with diabetes must have access to medications, diabetes technology (unless found to create a safety or security risk based on an individualized assessment), supplies for testing and daily management, and nutrition as needed to manage their disease. In people who do not meet treatment goals, medical and behavioral plans should be adjusted by HCPs in collaboration with the detention facility staff. It is critical for detention facilities to identify particularly high-risk individuals in need of more intensive evaluation and therapy, including pregnant people and individuals with advanced complications, a history of repeated severe hypoglycemia, or recurrent DKA.

In the detention setting environment, there are a number of reasonable accommodations that may be necessary and appropriate for people with diabetes, including modified meal times, special dietary plans, access to diabetes care supplies, access to food and drink to prevent and treat hypoglycemia, modified schedules and arrangements allowing participation in jobs or other programming, use of devices or other items to accommodate diabetes-related management needs (e.g., insulin pump) and medical complications (e.g., specialized shoes), and more.

A comprehensive, multidisciplinary approach to the care of people with diabetes can be an effective mechanism to improve overall health and to delay or prevent acute and chronic complications of this disease.

Acknowledgments. The following members of the American Diabetes Association National Commission on Correctional Health Care Joint Working Group on Diabetes Guidelines for Correctional Institutions contributed to the revision of this document in 2008: Daniel L. Lorber, MD, FACP, CDE (chair), R. Scott Chavez, MPA, PA-C, Joanne Dorman, RN, CDE, CCHP-A, Lynda K. Fisher, MD, Stephanie Guerken, RD, CDE, Linda B. Haas, CDE, RN, Joan V. Hill, CDE, RD, David Kendall, MD, Michael Puisis, DO, Kathy Salomone, CDE, MSW, APRN, Ronald M. Shansky, MD, MPH, and Barbara Wakeen, RD, LD.

The following members of the American Diabetes Association National Commission on Correctional Health Care Joint Working Group on Diabetes Guidelines for Correctional Institutions contributed to the revision of this document in 2020 and 2021: Daniel L. Lorber, MD, FACP, CDCES (chair), Nuha A. ElSayed, MD MM Sc, Raveendhara R. Bannuru, MD PhD, Viral Shah, MD, Michael Puisis, DO, Jill Crandall, MD, Sarah Fech-Baughman, JD, Barbara Wakeen, MA, RDN, LD, CD, CCFP, CCHP, Jo Jo Dantone, MS, RDN, LDN, CDCES, FAND, Robin Hunter-Buskey, DHSc, CPHQ, CCHP, CDCES, PA-C, CAPT, Kenneth Moritsugu, MD, MPH, FACPM, FADCES (hon), CCHP, Emily Wang, MD, Marisa Desimone, MD, Ruth Weinstock, MD, PhD, Aaron Fischer, JD, Jennifer Sherman, JD, Gabe Eber, JD, MPH, and William Shefelman, JD, MPH.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.