Every year, the American Diabetes Association (ADA) publishes their updated guidelines for the standards of medical care in diabetes. For 2016, the biggest changes was to management of obesity in treating Type 2 diabetes, changes with treatment of heart disease, and differences in care for certain populations of patients. The new guidelines also address updated goals for treatment, and new tools for evaluating the quality of care. They recommend adjusting treatment to improve the care of vulnerable populations. This gives clinicians a guide for treating differences and disparities in the areas of culture, ethnicity, socioeconomic, and gender. Guidelines include strategies for helping diabetes patients who struggle with cognitive problems, mental illness, food insecurity, and HIV.
The new guidelines were published online on December 22, 2015, in advance of the print publication in a supplement to the January edition of Diabetes Care.
The updates call for a tiered approach to the management of obesity. They look at lifestyle intervention, use of medications to treat obesity, and weight loss (bariatric) surgery. There is a new section on the medical and surgical management of people who have diabetes. It addresses previous bariatric surgery recommendations and provides guidance for a thorough assessment of weight in diabetes. It looks at using behavior change and medications to address overweight and obesity, and includes a new table of medications that are approved for the long-term treatment of obesity. Weight loss medications should be discontinued if less than 5% weight loss is achieved after three months of use. A 5% weight loss is targeted, by achieving a deficit of 500-750 calories per day. High intensity counseling interventions should number at least 16 sessions over a six month period of time, focusing on diet, physical activity, and behavior change. It gives guidance on maintaining the weight loss over the long term, and on achieving more than 5% weight loss in certain patients. Medications that are associated with weight gain should be minimized. For Type 2 patients with a Body Mass Index (BMI) greater than 35 kg/m2, bariatric surgery should be considered, especially if the disease and associated “other” health conditions are not responding well to lifestyle and medication interventions.
The ADA has updated its recommendations for atherosclerotic cardiovascular disease (ASCVD). Aspirin therapy should be considered for women at or over the age of 50 who have at least one additional risk factor, such as a family history of premature ASCVD, high blood pressure, high cholesterol, protein in the urine, or who smoke. Previous guidelines suggested aspirin should be considered for women over the age of 60, but recent research shows that younger women can benefit from aspirin. A medication section on treating people over age 75 was added. The new guidelines suggest that in certain diabetes patients, the cholesterol medication ezetimibe (Zetia) can provide benefit to the heart when added to a moderate-intensity statin. They added a table for clinicians that shows effectiveness and dosing details for high and moderate-intensity statin use.
Technology is playing an important role in the management of diabetes, and new recommendations support that people who use insulin pumps and Continuous Glucose Monitors (CGM) should continue to have access to these products at age 65 and beyond. Added safety comes from insulin pumps, low glucose suspend features, CGM, and linked systems–particularly for people who have hypoglycemia unawareness. People who are at risk of developing T2 diabetes should consider using new technologies like internet-based social networks, distance learning, and mobile apps to help them modify their behavior so that they may prevent diabetes.
Social issues need to be addressed, and strategies for diabetes management need to be individualized, patient-centered, and culturally appropriate. The obesity section and the vulnerable population section of the new guidelines are examples of where it is crucial to individualize care. People who have diabetes are also struggling with social issues such as an inability to get nutritious food (food insecurity), memory difficulties, mental illness, and HIV disease. There are also disparities with regard to ethnicity, culture, sex, and socioeconomic differences. People who have diabetes and food insecurity tend to struggle with high BG levels. Their diabetes management is often complicated by schedule, frequent consumption of high carbohydrate processed convenience foods, lack of food prep knowledge, access to adequate nutritive foods, and poor adherence to taking their diabetes medications because of money issues. Anxiety and depression can lead to poor self-care. Clinicians need to be aware of these risk factors for hyperglycemia (high BG) and actively address the issues so glucose control can improve. Other 2016 updates focus on treating different populations who have diabetes, addressing diabetes self-management education and support, psychological and social issues, and treatment of youth who have Type 2 diabetes. There is an in-depth section about older adults which gives guidance on treatment of issues such as memory difficulties, “other” health concerns that exist along with the diabetes, and ability to physically care for oneself. For women in their child-bearing years, there are recommendations on managing diabetes before and during pregnancy.
Who is at risk for getting diabetes?
Risk for diabetes and its complications differs by race, ethnicity, and socioeconomic status. Asian Americans are at risk for developing diabetes with a BMI of 23, yet for other groups, the risk begins at a BMI of 25. African Americans are at higher risk for high blood pressure and diabetic kidney disease than are other ethnic groups. We want to emphasize a patient-centered approach to diabetes management which meets the specific needs of the person with diabetes. Intensive control of BG levels will not improve memory difficulties in Type 2 patients with high BG levels. Their therapy should be tailored to avoid significant episodes of low BG. For patients who have HIV, before they start treatment with antiretroviral drugs, they should be screened for diabetes and pre-diabetes with a fasting glucose level. They should be screened again three months after starting or changing this drug therapy. If the results are normal, a fasting glucose level can then be checked yearly.
It’s a challenge to achieve control of diabetes–for patients, for caregivers, and for health care providers. The new Standards of Care outline the goals and make the management of diabetes a bit more within reach for everyone.