Psychological health, access to care, expanded and personalized treatment options, and the tracking of hypoglycemia in people with diabetes are key areas emphasized in the American Diabetes Association (ADA) 2017 Standards of Medical Care in Diabetes. Produced annually by the ADA, the guidelines focus on screening, diagnosis, and treatment to provide better health outcomes for children, adults, and older people with type-1, type-2, or gestational diabetes, and to improve the prevention and delay of type-2 diabetes.
The standards also include the findings of a new report on diabetes staging, titled “Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis.” Produced by a joint symposium of the ADA, JDRF, the European Association for the Study of Diabetes, and the American Association of Clinical Endocrinologists, the differentiation report focuses on beta-cell dysfunction and disease stage for type-1 and type-2 diabetes and outlines approaches to define distinct subtypes of diabetes to achieve personalized diabetes care. To produce this report, an expert team of 16 international leaders examined the available evidence on the genetic and environmental routes that result in diabetes, and how these pathways may be better characterized to allow precise, personalized treatment for people with diabetes.
“This year, the standards include critical, new evidence-based additions—psychosocial care, expanded physical fitness, metabolic surgery, and hypoglycemia—all of which can impact effective diabetes care,” said the ADA’s Chief Scientific and Medical Officer, Robert E. Ratner, MD, FACP, FACE. “Together, the new standards and the differentiation report will guide health care providers and patients around the world in a multidisciplinary approach to provide a comprehensive, individualized diabetes care plan—a plan that accounts for the whole patient and the many variables that can impact their ability to successfully manage diabetes, and thus leads to improved health outcomes.”
The 2017 Standards of Care incorporate several new guidelines issued in 2016 by the ADA, including those on physical activity, psychosocial health, metabolic surgery, and hypoglycemia (low blood glucose). Some highlights from the new evidence-based clinical and research recommendations in the 2017 standards are:
Assessment of psychological health and comorbidities
- Due to the greater risk of psychological/emotional stress and disorders in people with diabetes, the 2017 standards include guidelines on screening adults and youth with diabetes for diabetes distress (unique emotional issues related to the burdens and worries of living with diabetes), depression, anxiety, and eating disorders, and provide a list of situations that warrant a referral to a mental health specialist.
- The importance of assessing comorbidities as part of a comprehensive patient-centered evaluation is highlighted in the new standards. An expanded list of diabetes comorbidities now includes autoimmune disease, HIV, anxiety disorders, depression, disordered eating behavior, and serious mental illness.
- New lifestyle management guidelines in this year’s standards include a physical activity recommendation to interrupt prolonged sedentary behavior every 30 minutes. The standards now also advise that providers assess patients’ sleep patterns as part of overall diabetes care because sleep quality may be associated with blood glucose management.
Increased choice in treatment options
- The ADA’s recommendations on metabolic surgery for adults with type-2 diabetes have been revised. The standards have expanded the indications for metabolic surgery to include patients with inadequately controlled type-2 diabetes who have a body mass index as low as 30 kg/m2 (27.5 kg/m2 in Asian Americans).
- To provide more choices for people with diabetes who also have hypertension, medication recommendations have been expanded to include four options as first-line treatment. Any of the four classes of blood pressure medications that have shown beneficial cardiovascular outcomes in people with diabetes—angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, thiazide-like diuretics, or dihydropyridine calcium-channel blockers—may be used as initial therapy for hypertension.
- Included in this year’s pharmacological section is a new insulin algorithm, which offers more glucose management options for people with type-2 diabetes. A detailed care recommendation flow chart shows numerous pathways that may be considered for patients using insulin to meet their individual needs and hemoglobin A1c goals.
- Patients with diabetes and cardiovascular disease, which includes anyone with a history of stroke or heart attack, acute coronary syndromes, angina, or peripheral arterial disease, are at high risk of serious complications and death. Based on the results from two large clinical trials, the standards include a new recommendation to consider two specific glucose-lowering medications—the GLP-1 receptor agonist liraglutide and the SGLT-2 inhibitor empagliflozin—in this high-risk population to lower the risk of death. More research is needed to confirm if the heart benefits are a class effect or if the benefits persist in patients without established cardiovascular disease.
Additional important updates
- The ADA has updated guidelines on hypoglycemia indicating that a level of less than 54 mg/dL should be defined as denoting serious clinically important hypoglycemia, whether that level is associated with symptoms or not, and that incidences of hypoglycemia within that range be reported during clinical trials and in clinical practice.
- To assist providers in addressing any concerns about medication costs that patients living with diabetes face, two detailed tables have been added to this year’s standards. Each table estimates the average monthly costs of glucose-lowering medicines, both noninsulin and insulin, though the specific cost to the person with diabetes may vary.
- To help reduce health disparities, the standards now recommend people with diabetes receive self-management support from lay health coaches, navigators, and community health workers.
The standards are established and revised annually by a Professional Practice Committee, a multidisciplinary team of 12 leading experts on diabetes care that includes physicians, diabetes educators, registered dietitians, and others. The standards have been published as a supplement to the January 2017 issue of Diabetes Care.
Source: ADA; December 15, 2016; 2017 Standards; January 2017.