Diabetes Care Volume 37, Supplement 1, January 2014

S104

POSITION STATEMENT

Diabetes Management in
Correctional Institutions

American Diabetes Association

At any given time, over 2 million people are incarcerated in prisons and jails
in the U.S (1). It is estimated that nearly 80,000 of these inmates have diabetes, a
prevalence of 4.8% (2). In addition, many more people pass through the
corrections system in a given year. In 1998 alone, over 11 million people were
released from prison to the community (1). The current estimated prevalence of
diabetes in correctional institutions is somewhat lower than the overall U.S.
prevalence of diabetes, perhaps because the incarcerated population is younger
than the general population. The prevalence of diabetes and its related
comorbidities and complications, however, will continue to increase in the prison
population as current sentencing guidelines continue to increase the number of
aging prisoners and the incidence of diabetes in young people continues to
increase.
People with diabetes in correctional facilities should receive care that meets
national standards. Correctional institutions have unique circumstances that
need to be considered so that all standards of care may be achieved (3).
Correctional institutions should have written policies and procedures for the
management of diabetes and for training of medical and correctional 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 and equipment, so that all appropriate levels of care are provided.
Ideally, these policies should encourage or at least allow patients to self-manage
their diabetes. Ultimately, diabetes management is dependent upon having
access to needed medical personnel and equipment. Ongoing diabetes therapy is
important in order to reduce the risk of later complications, including
cardiovascular events, visual loss, renal failure, and amputation. Early
identification and intervention for people with diabetes is also likely to reduce
short-term risks for acute complications requiring transfer out of the facility, thus
improving security.
This document provides a general set of guidelines for diabetes care in correctional
institutions. It is not designed to be a diabetes management manual. More detailed
information on the management of diabetes and related disorders can be found in the
American Diabetes Association (ADA) Clinical Practice Recommendations, published
each year in January as the first supplement to Diabetes Care, as well as the “Standards
of Medical Care in Diabetes” (4) contained therein. This discussion will focus on those
areas where the care of people with diabetes in correctional facilities may differ, and
specific recommendations are made at the end of each section.
INTAKE MEDICAL ASSESSMENT
Reception Screening

Reception screening should emphasize patient safety. In particular, rapid
identification of all insulin-treated persons with diabetes is essential in order to
identify those at highest risk for hypo- and hyperglycemia and diabetic
ketoacidosis (DKA). All insulin-treated patients should have a capillary blood
glucose (CBG) determination within 1–2 h of arrival. Signs and symptoms of hypoor hyperglycemia can often be confused with intoxication or withdrawal from
drugs or alcohol. Individuals with diabetes exhibiting signs and symptoms
consistent with hypoglycemia, particularly altered mental status, agitation,
combativeness, and diaphoresis, should have finger-stick blood glucose levels
measured immediately.

Originally approved 1989. Most recent revision,
2008.
DOI: 10.2337/dc14-S104
© 2014 by the American Diabetes Association.
See http://creativecommons.org/licenses/bync-nd/3.0/ for details.

care.diabetesjournals.org

Position Statement

Intake Screening

Patients with a diagnosis of diabetes
should have a complete medical history
and physical examination by a licensed
health care provider with prescriptive
authority in a timely manner. If one is
not available on site, one should be
consulted by those performing
reception screening. The purposes of
this history and physical examination
are to determine the type of diabetes,
current therapy, alcohol use, and
behavioral health issues, as well as to
screen for the presence of diabetesrelated complications. The evaluation
should review the previous treatment
and the past history of both glycemic
control and diabetes complications. It is
essential that medication and medical
nutrition therapy (MNT) be continued
without interruption upon entry into
the correctional system, as a hiatus in
either medication or appropriate nutrition
may lead to either severe hypo- or
hyperglycemia that can rapidly progress
to irreversible complications, even death.

Intake Physical Examination and
Laboratory

All potential elements of the initial
medical evaluation are included in Table
7 of the ADA’s “Standards of Medical
Care in Diabetes,” referred to hereafter
as the “Standards of Care” (4). The
essential components of the initial
history and physical examination are
detailed in Fig. 1. Referrals should be
made immediately if the patient with
diabetes is pregnant.
Recommendations
c

c

c

Patients with a diagnosis of diabetes
should have a complete medical
history and undergo an intake physical
examination by a licensed health
professional in a timely manner. E
Insulin-treated patients should have a
CBG determination within 1–2 h of
arrival. E
Medications and MNT should be
continued without interruption
upon entry into the correctional
environment. E

SCREENING FOR DIABETES

Consistent with the ADA Standards of
Care, patients 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 blood glucose screening. If
pregnant, a risk assessment for
gestational diabetes mellitus (GDM)
should be undertaken at the first prenatal
visit. Patients with clinical characteristics
consistent with a high risk for GDM
should undergo glucose testing as soon as
possible. High-risk women not found to
have GDM at the initial screening and
average-risk women should be tested
between 24 and 28 weeks of gestation.
For more detailed information on
screening for both type 2 and gestational
diabetes, see the ADA Position Statement
“Screening for Type 2 Diabetes” (5) and
the Standards of Care (4).
MANAGEMENT PLAN

Glycemic control is fundamental to the
management of diabetes. A management

Within 1-2 hrs.

•Identify all inmates with diabetes currently using insulin therapy or at high risk for hypoglycemia
• ALL insulin-treated patients: screening CBG and urine ketone test (as clinically indicated)
• Any patient exhibiting signs/symptoms consistent with hypoglycemia: immediate CBG
•Continue usual meal schedule and medication administration

Within 2-24 hrs.
•Type and duration of diabetes
•Assess alcohol use
•Confirm current therapy
•Identify behavioral health issues
•Presence of complications
such as depression, distress, suicidal ideation
•Family history
•Assess prior diabetes education
•Pregnancy screen in all female patients
of childbearing age with diabetes
All subjects with diabetes should have physician evaluation. lfno physician available, physician should be consulted.

Within 2 hrs. - 2 weeks

Complete exam including:
•Height, weight
•Blood pressure
•Eye (retinal) exam
•Cardiac
•Peripheral pulses
•Foot and neurologic exam

Laboratory studies:
•AlC and glucose
•Lipid Profile
•Microalbumin screen (Alb/Cr ratio)
•Urine ketones (as clinically indicated)
•AST/ALT (as clinically indicated)
•Creatinine (as clinically indicated)

Figure 1—Essential components of the initial history and physical examination. Alb/Cr ratio, albumin-to-creatinine ratio; ALT, alanine
aminotransferase; AST, aspartate aminotransferase.

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Diabetes Care Volume 37, Supplement 1, January 2014

Position Statement

plan to achieve normal or near-normal
glycemia with an A1C goal of ,7%
should be developed for diabetes
management at the time of initial
medical evaluation. Goals should be
individualized (4), and less stringent
treatment goals may be appropriate
for patients with a history of severe
hypoglycemia, patients with limited
life expectancies, elderly adults, and
individuals with comorbid conditions
(4). This plan should be documented in
the patient’s record and communicated
to all persons involved in his/her care,
including security staff. Table 1, taken
from the ADA Standards of Care,
provides a summary of
recommendations for setting
glycemic control goals for adults with
diabetes.
People with diabetes should ideally
receive medical care from a physiciancoordinated team. Such teams include,
but are not limited to, physicians,
nurses, dietitians, and mental health
professionals with expertise and a
special interest in diabetes. It is
essential in this collaborative and
integrated team approach that
individuals with diabetes assume as
active a role in their care as possible.
Diabetes self-management education
is an integral component of care.
Patient self-management should be
emphasized, and the plan should
encourage the involvement of the
patient in problem solving as much as
possible.

Table 1—Summary of recommendations
for glycemic, blood pressure, and lipid
control for most adults with diabetes
A1C
,7.0%*
Blood pressure

,140/80 mmHg†

Lipids LDL
cholesterol

,100 mg/dL (,2.6
mmol/L)‡

*More or less stringent glycemic goals may
be appropriate for individual patients. Goals
should be individualized based on duration
of diabetes, age/life expectancy, comorbid
conditions, known CVD or advanced
microvascular complications, hypoglycemia
unawareness, individual and patient
considerations. †Based on patient
characteristics and response to therapy,
lower SBP targets may be appropriate.
‡In individuals with overt CVD, a lower LDL
cholesterol goal of ,70 mg/dL (1.8 mmol/L),
using a high dose of a statin, is an option.

It is helpful to house insulin-treated
patients in a common unit, if this is
possible, safe, and consistent with
providing access to other programs at
the correctional institution. Common
housing not only can facilitate
mealtimes and medication
administration, but also potentially
provides an opportunity for diabetes
self-management education to be
reinforced by fellow patients.
NUTRITION AND FOOD SERVICES

Nutrition counseling and menu
planning are an integral part of
the multidisciplinary approach to
diabetes management in correctional
facilities. A combination of education,
interdisciplinary communication, and
monitoring food intake aids patients in
understanding their medical nutritional
needs and can facilitate diabetes control
during and after incarceration.
Nutrition counseling for patients
with diabetes is considered an
essential component of diabetes selfmanagement. People with diabetes
should receive individualized MNT as
needed to achieve treatment goals,
preferably provided by a registered
dietitian familiar with the components
of MNT for persons with diabetes.
Educating the patient, individually or
in a group setting, about how
carbohydrates and food choices directly
affect diabetes control is the first step in
facilitating self-management. This
education enables the patient to
identify better food selections from
those available in the dining hall and
commissary. Such an approach is more
realistic in a facility where the patient
has the opportunity to make food
choices.
The easiest and most cost-effective
means to facilitate good outcomes in
patients with diabetes is instituting a
heart-healthy diet as the master menu
(6). There should be consistent
carbohydrate content at each meal, as
well as a means to identify the
carbohydrate content of each food
selection. Providing carbohydrate
content of food selections and/or
providing education in assessing
carbohydrate content enables patients
to meet the requirements of their
individual MNT goals. Commissaries

should also help in dietary management
by offering healthy choices and listing
the carbohydrate content of foods.
The use of insulin or oral medications
may necessitate snacks in order to avoid
hypoglycemia. These snacks are a part of
such patients’ medical treatment plans
and should be prescribed by medical
staff.
Timing of meals and snacks must be
coordinated with medication
administration as needed to minimize the
risk of hypoglycemia, as discussed more
fully in the MEDICATION section of this
document. For further information, see
the ADA Position Statement “Nutrition
Therapy Recommendations for the
Management of Adults With Diabetes” (7).
URGENT AND EMERGENCY ISSUES

All patients must have access to prompt
treatment of hypo- and hyperglycemia.
Correctional staff should be trained in
the recognition and treatment of hypoand hyperglycemia, and appropriate
staff should be trained to administer
glucagon. After such emergency care,
patients should be referred for
appropriate medical care to minimize
risk of future decompensation.
Institutions should implement a policy
requiring staff to notify a physician of all
CBG results outside of a specified range,
as determined by the treating physician
(e.g., ,50 or .350 mg/dL, ,2.8 or
.19.4 mmol/L).
Hyperglycemia

Severe hyperglycemia in a person
with diabetes may be the result of
intercurrent illness, missed or
inadequate medication, or
corticosteroid therapy. Correctional
institutions should have systems in
place to identify and refer to medical
staff all patients with consistently
elevated blood glucose as well as
intercurrent illness.
The stress of illness in those with type 1
diabetes frequently aggravates glycemic
control and necessitates more frequent
monitoring of blood glucose (e.g., every
4–6 h). Marked hyperglycemia requires
temporary adjustment of the treatment
program and, if accompanied by ketosis,
interaction with the diabetes care team.
Adequate fluid and caloric intake must
be ensured. Nausea or vomiting

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Position Statement

accompanied with hyperglycemia may
indicate DKA, a life-threatening
condition that requires immediate medical
care to prevent complications and death.
Correctional institutions should identify
patients with type 1 diabetes who are at
risk for DKA, particularly those with a prior
history of frequent episodes of DKA. For
further information see “Hyperglycemic
Crisis in Diabetes” (8).

severe hypoglycemia or recurrent
episodes of mild to moderate
hypoglycemia require reevaluation of
the diabetes management plan by the
medical staff. In certain cases of
unexplained or recurrent severe
hypoglycemia, it may be appropriate to
admit the patient to the medical unit for
observation and stabilization of
diabetes management.

Hypoglycemia

Correctional institutions should have
systems in place to identify the patients
at greater risk for hypoglycemia (i.e.,
those on insulin or sulfonylurea therapy)
and to ensure the early detection and
treatment of hypoglycemia. If possible,
patients 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 in order to minimize delay in
treatment.

Hypoglycemia is defined as a blood
glucose level ,70 mg/dL (3.9 mmol/L).
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. Signs and symptoms of severe
hypoglycemia can be confused with
intoxication or withdrawal. Individuals
with diabetes exhibiting signs and
symptoms consistent with
hypoglycemia, particularly altered
mental status, agitation, and
diaphoresis, should have their CBG
levels checked immediately.
Security staff who supervise patients at
risk for hypoglycemia (i.e., those on
insulin or oral hypoglycemic agents)
should be educated in the emergency
response protocol for recognition and
treatment of hypoglycemia. Every
attempt should be made to document
CBG before treatment. Patients must
have immediate access to glucose
tablets or other glucose-containing
foods. Hypoglycemia can generally be
treated by the patient with oral
carbohydrates. If the patient cannot be
relied on to keep hypoglycemia
treatment on his/her person, staff
members should have ready access to
glucose tablets or equivalent. In general,
15–20 g oral glucose will be adequate to
treat hypoglycemic events. CBG 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 injection or glucose for
intravenous infusion available to treat
severe hypoglycemia without requiring
transport of the hypoglycemic patient to
an outside facility. Any episode of

Recommendations
c

c
c

c

c

Train correctional staff in the
recognition, treatment, and
appropriate referral for hypo- and
hyperglycemia. E
Train appropriate staff to administer
glucagon. E
Train staff to recognize symptoms
and signs of serious metabolic
decompensation, and immediately
refer the patient for appropriate
medical care. E
Institutions should implement a policy
requiring staff to notify a physician of
all CBG results outside of a specified
range, as determined by the treating
physician (e.g., ,50 or .350 mg/dL,
,2.8 or .19.4 mmol/L). E
Identify patients with type 1 diabetes
who are at high risk for DKA. E

MEDICATION

Formularies should provide access to
usual and customary oral medications
and insulins necessary to treat
diabetes and related conditions.
While not every brand name of insulin
and oral medication needs to be
available, individual patient care
requires access to short-, medium-, and
long-acting insulins and the various
classes of oral medications (e.g., insulin
secretagogues, biguanides, a-glucosidase
inhibitors, DPP-4 inhibitors, and
thiazolidinediones) necessary for
current diabetes management.

Patients 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, patients on multiple doses of
short-acting oral medications should be
placed in a “keep on person” program. In
other situations, patients should be
permitted to self-inject insulin when
consistent with security needs. Medical
department nurses should determine
whether patients 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 patient
education. Reasonable syringe control
systems should be established.
In the past, the recommendation that
regular insulin be injected 30–45 min
before meals presented a significant
problem when “lock downs” or other
disruptions to the normal schedule of
meals and medications occurred. The
use of multiple-dose insulin regimens
using rapid-acting analogs can decrease
the disruption caused by such changes
in schedule. Correctional institutions
should have systems in place to ensure
that rapid-acting insulin analogs and
oral agents are given immediately
before meals if this is part of the
patient’s medical plan. It should be
noted, however, that even modest
delays in meal consumption with these
agents can be associated with
hypoglycemia. If consistent access to
food within 10 min cannot be ensured,
rapid-acting insulin analogs and oral
agents are approved for administration
during or immediately after meals.
Should circumstances arise that delay
patient access to regular meals
following medication administration,
policies and procedures must be
implemented to ensure the patient
receives appropriate nutrition to
prevent hypoglycemia.
The sole use of sliding scale insulin is
strongly discouraged. Both continuous
subcutaneous insulin infusion and
multiple daily insulin injection therapy
(consisting of three or more injections a
day) can be effective means of
implementing intensive diabetes
management with the goal of achieving
near-normal levels of blood glucose (9).

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Diabetes Care Volume 37, Supplement 1, January 2014

Position Statement

While the use of these modalities may
be difficult in correctional institutions,
every effort should be made to continue
multiple daily insulin injection or
continuous subcutaneous insulin
infusion in people who were using this
therapy before incarceration or to
institute these therapies as indicated in
order to achieve blood glucose targets.
It is essential that transport of patients
from jails or prisons to off-site
appointments, such as medical visits or
court appearances, does not cause
significant disruption in medication or
meal timing. Correctional institutions and
police lock-ups should implement policies
and procedures to diminish the risk of
hypo- and hyperglycemia by, for example,
providing carry-along meals and
medication for patients traveling to offsite appointments or changing the insulin
regimen for that day. The availability of
prefilled insulin “pens” provides an
alternative for off-site insulin delivery.

The following complications should be
considered:
c

c

Recommendations
c

c

c

Formularies should provide access to
usual and customary oral medications
and insulins to treat diabetes and
related conditions. E
Patients should have access to
medication at dosing frequencies that
are consistent with their treatment
plan and medical direction. E
Correctional institutions and police
lock-ups should implement policies
and procedures to diminish the risk
of hypo- and hyperglycemia during
off-site travel (e.g., court
appearances). E

c

c

ROUTINE SCREENING FOR AND
MANAGEMENT OF DIABETES
COMPLICATIONS

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

Foot care: Recommendations for foot
care for patients with diabetes and no
history of an open foot lesion are
described in the ADA Standards of
Care. A comprehensive foot
examination is recommended
annually for all patients with diabetes
to identify risk factors predictive of
ulcers and amputations. Persons with
an insensate foot, an open foot
lesion, or a history of such a lesion
should be referred for evaluation by
an appropriate licensed health
professional (e.g., podiatrist or
vascular surgeon). Special shoes
should be provided as recommended
by licensed health professionals to aid
healing of foot lesions and to prevent
development of new lesions.
Retinopathy: Annual retinal
examinations by a licensed eye care
professional should be performed for
all patients with diabetes, as
recommended in the ADA Standards
of Care. Visual changes that cannot be
accounted for by acute changes in
glycemic control require prompt
evaluation by an eye care
professional.
Nephropathy: An annual spot urine
test for determination of
microalbumin-to-creatinine ratio
should be performed. The use of ACE
inhibitors or angiotensin receptor
blockers is recommended for all
patients with albuminuria. Blood
pressure should be controlled to
,140/80 mmHg.
Cardiac: People with type 2 diabetes
are at a particularly high risk of
coronary artery disease.
Cardiovascular disease (CVD) risk
factor management is of
demonstrated benefit in reducing this
complication in patients with
diabetes. Blood pressure should be
measured at every routine diabetes
visit. In adult patients, test for lipid
disorders at least annually and as
needed to achieve goals with
treatment. Use aspirin therapy (75–
162 mg/day) in all adult patients with
diabetes and cardiovascular risk
factors or known macrovascular
disease. Current national standards
for adults with diabetes call for

treatment of lipids to goals of LDL
#100, HDL .40, triglycerides ,150
mg/dL, and blood pressure to a level
of ,140/80 mmHg.
MONITORING/TESTS OF GLYCEMIA

Monitoring of CBG is a strategy that
allows caregivers and people with
diabetes to evaluate diabetes
management regimens. The frequency
of monitoring will vary by patients’
glycemic control and diabetes regimens.
Patients with type 1 diabetes are at risk
for hypoglycemia and should have their
CBG monitored three or more times
daily. Patients with type 2 diabetes on
insulin need to monitor at least once
daily and more frequently based on
their medical plan. Patients treated
with oral agents should have CBG
monitored with sufficient frequency to
facilitate the goals of glycemic control,
assuming that there is a program for
medical review of these data on an
ongoing basis to drive changes in
medications. Patients whose diabetes is
poorly controlled or whose therapy is
changing should have more frequent
monitoring. Unexplained hyperglycemia
in a patient with type 1 diabetes may
suggest impending DKA, and monitoring
of ketones should therefore be
performed.
Glycated hemoglobin (A1C) is a
measure of long-term (2- to 3-month)
glycemic control. Perform the A1C test
at least two times a year in patients who
are meeting treatment goals (and who
have stable glycemic control) and
quarterly in patients whose therapy has
changed or who are not meeting
glycemic goals.
Discrepancies between CBG monitoring
results and A1C may indicate a
hemoglobinopathy, hemolysis, or need
for evaluation of CBG monitoring
technique and equipment or initiation
of more frequent CBG monitoring to
identify when glycemic excursions are
occurring and which facet of the
diabetes regimen is changing.
In the correctional setting, policies and
procedures need to be developed and
implemented regarding CBG monitoring
that address the following:
c
c

infection control
education of staff and patients

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c
c
c
c
c
c
c
c

Position Statement

proper choice of meter
disposal of testing lancets
quality control programs
access to health services
size of the blood sample
patient performance skills
documentation and interpretation of
test results
availability of test results for the
health care provider (10)

Recommendations
c

c

In the correctional setting, policies
and procedures need to be developed
and implemented to enable CBG
monitoring to occur at the frequency
necessitated by the individual
patient’s glycemic control and
diabetes regimen. E
A1C should be checked every 3–6
months. E

SELF-MANAGEMENT EDUCATION

Self-management education is the
cornerstone of treatment for all people
with diabetes. The health staff must
advocate for patients 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. In the
development of a diabetes selfmanagement education program in the
correctional environment, the unique
circumstances of the patient should be
considered while still providing, to the
greatest extent possible, the elements
of the “National Standards for Diabetes
Self-Management Education and
Support” (11). A staged approach may

Table 2—Major components
Survival skills
c hypo-/hyperglycemia
c sick day management
c medication
c monitoring
c foot care

be used depending on the needs
assessment and the length of
incarceration. Table 2 sets out the
major components of diabetes selfmanagement education. Survival skills
should be addressed as soon as
possible; other aspects of education
may be provided as part of an ongoing
education program.

c

Ideally, self-management education is
coordinated by a certified diabetes
educator who works with the facility to
develop polices, procedures, and
protocols to ensure that nationally
recognized education guidelines are
implemented. The educator is also
able to identify patients who need
diabetes self-management education,
including an assessment of the
patients’ medical, social, and diabetes
histories; diabetes knowledge, skills,
and behaviors; and readiness to
change.

c

STAFF EDUCATION

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 persons
with diabetes. The health care staff
needs to be involved in the
development of the correctional
officers’ training program. The staff
education program should be at a lay
level. Training should be offered at
least biannually, and the curriculum
should cover the following:
c
c
c

what diabetes is
signs and symptoms of diabetes
risk factors

of diabetes self-management education
Daily management issues
c disease process
c nutritional management
c physical activity
c medications
c monitoring
c acute complications
c risk reduction
c goal setting/problem solving
c psychosocial adjustment
c preconception care/pregnancy/gestational diabetes
management

c
c
c
c

signs and symptoms of, and
emergency response to, hypo- and
hyperglycemia
glucose monitoring
medications
exercise
nutrition issues including timing of
meals and access to snacks

Recommendations

Include diabetes in correctional staff
education programs. E

ALCOHOL AND DRUGS

Patients with diabetes who are
withdrawing from drugs and alcohol
need special consideration. This issue
particularly affects initial police custody
and jails. At an intake facility, proper
initial identification and assessment of
these patients are critical. The presence
of diabetes may complicate
detoxification. Patients in need of
complicated detoxification should be
referred to a facility equipped to deal
with high-risk detoxification. Patients
with diabetes should be educated in the
risks involved with smoking. All inmates
should be advised not to smoke.
Assistance in smoking cessation should
be provided as practical.
TRANSFER AND DISCHARGE

Patients in jails may be housed for a
short period of time before being
transferred or released, and it is not
unusual for patients in prison to be
transferred within the system several
times during their incarceration. One of
the many challenges that health care
providers face working in the
correctional system is how to best
collect and communicate important
health care information in a timely
manner when a patient is in initial police
custody, is jailed short term, or is
transferred from facility to facility. The
importance of this communication
becomes critical when the patient has a
chronic illness such as diabetes.
Transferring a patient with diabetes
from one correctional 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 medical
staff with sufficient notice before
movement of the patient.

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Position Statement

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

c

c

the patient’s current medication
schedule and dosages
the date and time of the last
medication administration
any recent monitoring results (e.g.,
CBG 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, presence of
diabetes complications)
information on scheduled treatment/
appointments if the receiving facility
is responsible for transporting the
patient to that appointment
name and telephone/fax number of a
contact person at the transferring
facility who can provide additional
information, if needed

The medical transfer summary, which
acts as a quick medical reference for the
receiving facility, should be transferred
along with the patient. 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 patient
with a medication card to be carried by
the patient that contains information
concerning diagnoses, medication
names, dosages, and frequency. Diabetes
supplies, including diabetes medication,
should accompany the patient.
The sending facility must be mindful of
the transfer time in order to provide the
patient 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 patients’ discharge from
prisons 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
patients may obtain regular follow-up
medical care. A quarterly meeting to
educate patients 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
patients discharging from correctional
facilities.
Discharge planning for the patients with
diabetes should begin 1 month before
discharge. During this time, application
for appropriate entitlements should be
initiated. Any gaps in the patient’s
knowledge of diabetes care need to be
identified and addressed. It is helpful if
the patient is given a directory or list of
community resources and if an
appointment for follow-up care with a
community provider is made. A supply
of medication adequate to last until the
first postrelease medical appointment
should be provided to the patient upon
release. The patient should be provided
with a written summary of his/her
current health care issues, including
medications and doses, recent A1C
values, etc.
Recommendations
c

c

c

For all interinstitutional transfers,
complete a medical transfer summary
to be transferred with the patient. E
Diabetes supplies and medication
should accompany the patient during
transfer. E
Begin discharge planning with
adequate lead time to insure
continuity of care and facilitate entry
into community diabetes care. E

SHARING OF MEDICAL
INFORMATION AND RECORDS

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

Facilities that use outside medical
providers should implement policies
and procedures for ensuring that key
information (e.g., test results,
diagnoses, physicians’ orders,
appointment dates) is received from
the provider and incorporated into the
patient’s medical chart after each
outside appointment. The procedure
should include, at a minimum, a
means to highlight when key
information has not been received and
designation of a person responsible for
contacting the outside provider for this
information.
All medical charts should contain CBG
test results in a specified, readily
accessible section and should be
reviewed on a regular basis.
CHILDREN AND ADOLESCENTS
WITH DIABETES

Children and adolescents with diabetes,
in particular type 1, present special
problems in disease management, even
outside the setting of a correctional
institution. Children and adolescents with
diabetes should have initial and follow-up
care with physicians who are experienced
in their care. Confinement increases the
difficulty in managing diabetes in children
and adolescents, as it does in adults with
diabetes. Correctional authorities also
have different legal obligations for
children and adolescents.
Nutrition and Activity

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.
The provision of an adequate amount of
calories and nutrients for adolescents is
critical to maintaining good nutritional
status. Physical activity should be
provided at the same time each day. If
increased physical activity occurs,
additional CBG monitoring is necessary
and additional carbohydrate snacks may
be required.
Medical Management and Follow-up

Children and adolescents who are
incarcerated for extended periods
should have follow-up visits at least
every 3 months with individuals who are
experienced in the care of children and
adolescents with diabetes. Thyroid

care.diabetesjournals.org

Position Statement

function tests and fasting lipid and
microalbumin measurements should be
performed according to recognized
standards for children and adolescents
(12) in order to monitor for autoimmune
thyroid disease and complications and
comorbidities of diabetes.

institutions to identify particularly
high-risk patients in need of more
intensive evaluation and therapy,
including pregnant women, patients
with advanced complications, a history
of repeated severe hypoglycemia, or
recurrent DKA.

Children and adolescents with diabetes
exhibiting unusual behavior should have
their CBG checked at that time. Because
children and adolescents are reported
to have higher rates of nocturnal
hypoglycemia (13), consideration
should be given regarding the use of
episodic overnight blood glucose
monitoring in these patients. In
particular, this should be considered in
children and adolescents who have
recently had their overnight insulin dose
changed.

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

PREGNANCY

Pregnancy in a woman with diabetes is
by definition a high-risk pregnancy.
Every effort should be made to ensure
that treatment of the pregnant woman
with diabetes meets accepted standards
(14,15). It should be noted that glycemic
standards are more stringent, the
details of dietary management are more
complex and exacting, insulin is the
only antidiabetic agent approved for
use in pregnancy, and a number of
medications used in the management of
diabetic comorbidities are known to be
teratogenic and must be discontinued in
the setting of pregnancy.
SUMMARY AND KEY POINTS

People with diabetes should receive
care that meets national standards.
Being incarcerated does not change
these standards. Patients must have
access to medication and nutrition
needed to manage their disease. In
patients who do not meet treatment
targets, medical and behavioral plans
should be adjusted by health care
professionals in collaboration with the
prison staff. It is critical for correctional

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:
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.

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