To estimate the proportion of U.S. adults with diabetes who meet American Diabetes Association (ADA) clinical practice recommendations. Using data from the 1999-2002 National Health and Nutrition Examination Survey, 998 adults aged >/=18 years with self-reported diabetes were identified. The proportion of adults with diabetes meeting ADA recommendations for HbA(1c) (A1C), HDL cholesterol, LDL cholesterol, triglycerides, blood pressure, renal function, nutrient intake, smoking, pneumococcal vaccination, and physical activity was estimated. Among U.S. adults with diabetes in 1999-2002, 49.8% had A1C <7%; 27.4, 36.0, and 65.0% were classified as low risk for HDL cholesterol, LDL cholesterol, and triglycerides, respectively. Nearly 40% met blood pressure recommendations, 66% had normal renal function, and daily nutrient recommendations for protein, saturated fat, unsaturated fat, and fiber were met by 64.0, 48.3, 28.3, and 18.3%, respectively. Although >81% of the sample reported not smoking at the time of the exam, only 38.2% reported ever having had a pneumococcal immunization, and 28.2% reported getting the recommended level of physical activity. Race, age, duration of diabetes, and education affected achievement of ADA recommendations. Achievement of ADA clinical practice recommendations is far from adequate in U.S. adults with diabetes.