- ACC Endorses New ADA 2019 Standards of Medical Care in Diabetes
- New diabetes guidelines downgrade insulin as first-line injectable treatment
- Diabetes treatment
- Diabetes monitoring and screening
- Diabetes Care Standards
- Objective of Section
- Guiding Principles for the Care of People With or At Risk for Diabetes
- Organizational Practice Guidelines
- New Diabetes Recommendations Challenge Decades-Old Guidelines
- A new look at A1C
- New recommendations may face backlash
- What’s New in the 2019 ADA “Standards of Diabetes Care”
- American Diabetes Association Releases 2019 Standards of Care
- What Are the ADA Standards of Care and Why Should You Care?
- An Overview of the Main Tenets of the 2019 ADA Standards of Care
- How People Living With Diabetes Can Take Advantage of the New ADA Guidelines
ACC Endorses New ADA 2019 Standards of Medical Care in Diabetes
The American Diabetes Association has released its 2019 Standards of Medical Care in Diabetes (Standards of Care), which include new and revised clinical practice recommendations that provide a roadmap for therapeutic approaches and medication selection based on each patient’s overall health status. The ACC has endorsed the new standards, which include updates aimed at reducing heart attacks, strokes, heart failure and other manifestations of cardiovascular disease.
“The latest evidence-based research continues to provide critical information that can optimize treatment options and improve patient outcomes and quality of life. The new 2019 Standards of Care emphasize a patient-centered approach that considers the multiple health and life factors of each person living with diabetes,” said ADA’s Chief Scientific, Medical and Mission Officer William T. Cefalu, MD. “We are also pleased about our close collaboration with the ACC, aligning the ADA’s CVD recommendations with the ACC for the first time ever.”
The Standards of care includes several important updates and additions including recommendations for greater personalization of care and the need for ongoing assessment and shared decision-making; expanded treatment recommendations for children and adolescents with type 2 diabetes; a new section on diabetes and technology, including used of telemedicine; and information on medical nutrition, as well as pharmacologic approaches and glycemic targets. On the cardiovascular front, highlights from the cardiovascular disease management chapter include:
- New language to acknowledge heart failure as a major cause of cardiovascular morbidity and mortality in people with diabetes and the need to consider heart failure when determining optimal diabetes care
- Updated recommendations detailing the use of sodium–glucose cotransporter 2 (SGLT-2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists
- A new recommendation outlining the benefits of GLP-1 receptor agonists and SGLT-2 inhibitors for people with type 2 diabetes and chronic kidney disease.
- An endorsement of the ACC’s atherosclerotic cardiovascular disease (ASCVD) risk calculator, the ASCVD Risk Estimator Plus, for the routine assessment of 10-year ASCVD risk in people with diabetes.
“The American College of Cardiology and the American Diabetes Association share a goal to reduce the burden of cardiovascular disease that too often follows a diabetes diagnosis,” said ACC Vice President Richard Kovacs, MD, FACC. “ACC is proud to stand behind this important document that will provide a roadmap for clinicians to effectively assess and manage cardiovascular disease in patients with diabetes and, in turn, save lives.”
Read the complete document.
Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Lipid Metabolism, Acute Heart Failure
Keywords: Diabetes Mellitus, Type 2, Quality of Life, Standard of Care, Blood Glucose, Atherosclerosis, Stroke, Heart Failure, Myocardial Infarction, Renal Insufficiency, Chronic, Telemedicine, Decision Making, Sodium-Glucose Transport Proteins, Glucagon-Like Peptide 1
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New diabetes guidelines downgrade insulin as first-line injectable treatment
The American Diabetes Association is out with new standard-of-care guidelines that – among other things – reject injectable insulin as the main first-line treatment for type 2 diabetes mellitus (T2DM), debut a cardiac risk calculator, and offer new recommendations regarding medications for patients with kidney disease, clogged arteries, and heart failure.
The ADA’s newly released 2019 Standards of Medical Care in Diabetes “emphasize a patient-centered approach that considers the multiple health and life factors of each person living with diabetes,” said William T. Cefalu, MD, the ADA’s chief scientific, medical, and mission officer, in a statement.
The 193-page guidelines are now available online at the Diabetes Care website and will be available via an app and the print edition of the journal.
Here’s a closer look at a few of the many new and revised recommendations in the 2019 Standards of Care.
In a new guideline, the standards of care says glucagonlike peptide–1 (GLP-1) receptor agonists should be “a first-line treatment” – ahead of insulin – “for most patients who need the greater efficacy of an injectable medication.”
However, the recommendations note that the “high costs and tolerability issues are important barriers to the use of GLP-1 receptor agonists.”
A new recommendation suggests the use of sodium-glucose cotransporter 2 inhibitors or GLP-1 receptor agonists “with demonstrated cardiovascular disease benefit” in patients with type 2 diabetes who have confirmed atherosclerotic cardiovascular disease.
A related new recommendation says sodium-glucose cotransporter 2 inhibitors are the preferred treatment for these patients who have heart failure or are at high risk of developing it.
In a new recommendation, the ADA suggests that patients with type 2 diabetes and chronic kidney disease potentially take a sodium-glucose cotransporter 2 inhibitor or a GLP-1 receptor agonist, which has been shown to reduce the risk of chronic kidney disease progression, cardiac events, or both.
There’s a greater focus on insulin as the preferred treatment for hyperglycemia in gestational diabetes mellitus “as it does not cross the placenta to a measurable extent.” The ADA also warns against metformin and glyburide as first-line agents because they “both cross the placenta to the fetus.”
Diabetes monitoring and screening
The ADA now recommends use of the American College of Cardiology’s atherosclerotic cardiovascular disease risk calculator, the ASCVD Risk Estimator Plus. The calculator assesses the risk of this disease over 10 years and is “generally a useful tool.”
The ACA recommends screening for cardiac risk factors at least once a year in patients with diabetes.
Physicians are no longer advised to check the feet of patients with diabetes at every visit; now the recommendation is for those at high risk of ulceration only. However, an annual examination of feet is recommended for all patients with diabetes.
The ADA now recommends that patients with type 2 diabetes or prediabetes undergo screening for nonalcoholic steatohepatitis and liver fibrosis if they have elevated liver enzymes or an ultrasound examination shows signs of fatty liver.
Gabapentin is now listed along with pregabalin and duloxetine as first-line drug treatments for neuropathic pain in diabetes.
Diabetes Care Standards
Objective of Section
This section shares resources that provide evidence-based guidelines to support and improve care for people with diabetes.
Guiding Principles for the Care of People With or At Risk for Diabetes
The National Diabetes Education Program (NDEP) maintains a set of clinically useful principles that highlight areas of agreement in diabetes management and prevention. This resource, the Guiding Principles for the Care of People With or At Risk for Diabetes, provides health care professionals a set of 10 guiding principles that highlight areas of agreement for diabetes care. More than a dozen federal agencies and professional organizations support this document.
Organizational Practice Guidelines
The goal of any set of guidelines is to improve patient outcomes. A part of quality improvement or pay-for-performance measures may include collection of data from health care practices to document the achievement of these goals.
A variety of organizations provide recommendations to assist with the screening, prevention, and management of diabetes. Recommendations can be based on a systematic review of the literature, review of existing guidelines, or best practice advice.
Below is a list of organizations and the diabetes practice guidelines they provide:
- American Academy of Family Physicians: Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents
- The American Association of Clinical Endocrinologists: Clinical Practice Guidelines
- American College of Physicians: Comparative Guideline Table: Screening for Diabetes
- American Diabetes Association: 2016 Standards of Medical Care in Diabetes
- American Heart Association: Diabetes Mellitus
- The American Geriatrics Society: Guidelines for Improving the Care of Older Adults with Diabetes Mellitus
- Endocrine Society: Clinical Practice Guidelines
- National Committee for Quality Assurance: Diabetes Recognition Program
- U.S. Preventive Services Task Force: Published Recommendations
New Diabetes Recommendations Challenge Decades-Old Guidelines
A new report is challenging decades of diabetes treatment dogma by advising that people with type 2 diabetes should have more relaxed targets for a blood protein used to help monitor blood sugar levels.
Some patients are even advised to “de-intensify” their medication or go off it altogether.
The recommendations from the American College of Physicians (ACP) centers around a protein called hemoglobin HbA1C or “A1C,” which is key in helping people with diabetes to monitor their average blood sugar level. Sugars or glucose bind to hemoglobin as they travel through the bloodstream.
A new look at A1C
For years, the American Diabetes Association (ADA) has recommended that all people with diabetes aim for a target hemoglobin HbA1C level below 7 percent.
Even more stringent, the American Association of Clinical Endocrinologists (AACE) recommends A1C targets below 6.5 percent.
But the recent report from the ACP completely contradicts the ADA and the AACE. It recommends most patients with type 2 diabetes should aim for much higher A1Cs — between 7 and 8 percent.
Your A1C measures the amount of advanced glycogenated end products (AGEs) that have accumulated in your bloodstream during the prior three months.
This measurement is then translated into a person’s average blood sugar level for this time, also known as your estimated average glucose (eAG).
The ACP recommendation works directly against decades’ worth of diabetes education guidelines that suggest an A1C over 7 percent increases a person’s risk of developing diabetes complications such as retinopathy and neuropathy.
People without diabetes generally measure with A1Cs below 5.7, with the healthiest individuals measuring below 5.0 percent, which means blood levels rarely wander out of the 70 to 130 mg/dL range.
For diagnosis, having A1Cs higher than 5.7 is considered prediabetes, and A1Cs at 6.5 or higher is diabetes.
Suggesting people purposefully allow their blood sugars to remain consistently high enough to measure an A1C between 7 to 8 percent translates to blood sugar levels persisting between 150 to 200 mg/dL, well above what’s considered healthy.
However, the ACP is recommending these high blood sugar targets because the evidence suggesting A1Cs in this higher range contribute to complications is “inconsistent” and only seen in patients with an excess of protein in their urine, suggesting preexisting kidney issues.
Instead of focusing on the fear of complications, the ACP’s primary focus is vastly different and centered on patients’ individual needs.
“The ACP recommends that clinicians should personalize goals for blood sugar control in patients with type 2 diabetes based on a discussion of benefits and harms of drug therapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care,” explained the report.
Additionally, the ACP is suggesting that patients who have achieved A1C targets below 6.5 percent should actually “de-intensify” their diabetes management by reducing their medication doses or even taking them off one of their medications altogether.
New recommendations may face backlash
Considering how much pride and effort goes into achieving an A1C below 6.5 percent, many people will likely balk at the suggestion that after years of hard work they ought to let their blood sugar rise above traditionally healthy ranges.
“General recommendations like these are of limited value,” said Gary Scheiner, CDE, MS, of Integrated Diabetes Services. “I believe this recommendation in particular fails to individualize care to the patient.”
“Many patients with type 2 diabetes can and should be aiming for tighter control than what is recommended here. Those at low risk of hypoglycemia but high risk of vascular complications would likely benefit from an A1C below 7 percent,” added Scheiner, author of the acclaimed diabetes management guide, “Think Like a Pancreas.”
“In addition,” Scheiner warned, “the day-to-day function of the individual is affected greatly by glucose control, not just long-term health risks. Targeting higher glucose levels limits a person’s ability to perform optimally from a physical, intellectual, and emotional standpoint.”
One aspect of the ACP’s recommendations that may be less controversial is the emphasis that patients with a life expectancy of 10 years or less (who are generally 80 years or older) or people with chronic conditions on top of diabetes, should focus on minimizing high blood sugar symptoms rather than focusing on their A1C levels.
The only exception to their looser guidelines?
People who are managing their type 2 diabetes through diet and lifestyle modifications alone have their blessing to continue aiming for A1C targets below 7 percent.
Ginger Vieira is an expert patient living with type 1 diabetes, celiac disease, and fibromyalgia. Find her books on diabetes on Amazon.com and connect with her on Twitter and YouTube.
What’s New in the 2019 ADA “Standards of Diabetes Care”
It’s that time of year again. No, not post-holiday clearance sales. Not New Year’s resolution regrets. Not taxes. (Even though all those things are happening). No, we’re talking about the annual diabetes tradition from the American Diabetes Association (ADA): They have released their updated Standards of Medical Care for those of us with diabetes. All 159 pages of them.
Why does this matter? Because, like EF Hutton, when the ADA talks, people listen. Well… at least doctors do. So if the ADA changes something, like say dropping the decades-old advice that all PWDs take a daily aspirin—which they did a number of years ago—your treatment will likely change. The Standards also have an impact on health policy and insurance coverage, so we are well-advised to pay attention.
What’s new in this year’s Standards? Anything shocking?
Well, there’s no reason to stop the presses, but there is some interesting stuff this year. Among other things, the ADA has a new focus on technology, wants us in no uncertain terms to pay attention to our hearts, and advises us to drink more water. On the bright side, you can leave your shoes on at the endo’s office and put salt on your French fries again. And some of you can throw your meters in the trash. Oh, and like in the rest of the medical world, there’s an expansion of focus on the buzz-happy notion of “patient-centered medicine,” and a new primer for teaching doctors how to talk to patients. Again.
A New Focus on Tech
The biggest change in the Standards this year is the addition of a whole new section: D-tech now has its very own independent segment in the Standards, set to include recommendations on meters, CGMs, insulin delivery devices, and more. Quoting the Standards document, “The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge… To that end, the ‘Standards of Medical Care in Diabetes’ (Standards of Care) now includes a dedicated section on Diabetes Technology, which contains preexisting material that was previously in other sections that has been consolidated, as well as new recommendations.”
In its first time out of the gate, the new tech section of the Standards is focused solely on insulin delivery and glucose monitoring, but we are promised that in future years: “this section will be expanded to include software as a medical device, privacy, cost, technology-enabled diabetes education and support, telemedicine, and other issues that providers and patients encounter with the use of technology in modern diabetes care.”
Anything interesting in there? The ADA likes CGM and new “flash” (intermittently scanned) meters, and is excited about the future potential of automated insulin delivery. But for the first time, the org has begun to question the use of the old-fashioned fingerstick for PWDs not on insulin, stating, “The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population.” Which makes sense, given that most insurance companies will only give this population one strip per day, although the ADA did point to a study by Dr. William Polonsky showing that using structured testing quarterly lowered A1C by 0.3%, which is better than some meds.
Meanwhile, in a separate section on improving care and promoting health, the ADA gives a nod to telemedicine (including web portals and text messaging) as a “growing field that may increase access to care for patients with diabetes,” especially “rural populations or those with limited physical access to health care.”
For the first time, the American College of Cardiology (ACC) is on board with the ADA, endorsing the new Standards; while the ADA in turn endorsed the ACC’s atherosclerotic cardiovascular disease risk calculator, called ASCVD Risk Estimator Plus. If you’re not familiar with ASCVD, it’s coronary heart disease, cerebrovascular disease, and peripheral arterial disease, all lumped together. So basically, heart attacks, strokes, and all other bad heart ailments than can befall you. The ADA has been cheered by many heart docs for pulling no punches this year and clearly spelling out the dark facts in the Standards: “ASCVD… is the leading cause of morbidity and mortality for individuals with diabetes.”
Meet the Reaper. You can try it out yourself. The calculator that is, not death.
Enter some quick demographics (age, sex, and race all play parts in the risk) plus your blood pressure, cholesterol, smoking status, and a few details on your meds, and the calculator spits out your ten-year, and lifetime, risk of ASCVD. Then the fun begins. Click on the “determine therapy impact” button, and the calculator lets you click and unclick various therapy options to show to what percent various interventions reduce your risk.
It’s more entertaining than Pacman.
But the key message here is that even though heart stuff is the big killer, there’s much we can do to reduce our risk, and the Standards point out that “risk among U.S. adults with diabetes have improved significantly over the past decade.”
The ADA has also created a new cardiovascular education program in collaboration with the American Heart Association called Know Diabetes by Heat.
‘Patient-Centered Care’ for 2019… (Really?!)
This year, patient-centered care is “the focus and priority” of the Standards, according to an ADA press release. Really? Doesn’t that put the ADA about four years behind everybody else? Actually, this year’s Standards gives the exact same recommendation to adopt patient-centered care in diabetes treatment as it did in the 2018 Standards and the 2017 Standards before that.
What’s new this year is an expansion of supporting materials for diabetes-treating docs, including a number of new treatment algorithms to help docs to shift their mindsets and practice styles into a more patient-centered approach.
Also on the Menu
Drink more water, the Standards tell us, and fewer beverages with noncaloric sweeteners (i.e. diet soda). But when it comes to food, the ADA—no doubt still smarting from the legacy of the infamous “ADA diet”—emphasizes that there’s no one-size-fits-all eating pattern. Rather than giving docs a set of menus, the ADA advises packing patients off to a registered dietitian to “work collaboratively with the patient to create a personalized meal plan that considers the individual’s health status, skills, resources, food preferences.”
Although the Standards do give a thumbs up to the Mediterranean, DASH, and plant-based diets, as approaches that all “have shown positive results in research.” The ADA also says low-carb works for sugar control, but that studies show “challenges with long-term sustainability.”
In other good news, if you have both hypertension and diabetes, you no longer need to restrict your sodium intake beyond the level recommended for the general population of less than 2,300 mg per day (previously, it had been below 1,500 mg).
In the Medicine Cabinet
GLP1 is now first choice of injectables, before insulin, for T2s who aren’t reaching target goals on oral meds. And speaking of injections, a new section was added on proper injection technique to avoid lipodystrophy.
In other drug news, gabapentin (brand name Neurontin) is now on the neuropathic pain list due to “strong efficacy and the potential for cost savings.” And there Standards include a new table to help doctors assess risk of hypoglycemia.
- Keep your shoes on: the new Standards have shied away from foot inspections at every visit (except for those PWDs at high risk for ulceration); instead, and annual foot exam will do.
- Double checking: There’s a new recommendation to confirm a diabetes diagnosis with a second test from the same sample, for example doing both a fingerstick and an A1C from the same blood drop.
- Smoking included: Because smoking may increase the risk of type 2, a section on tobacco was added to the chapter on the prevention or delay of type 2 diabetes.
- No pills for expecting moms: Insulin is now on top of the list for pregnant women with sugar issues, as metformin and glyburide have both been shown to cross the placenta, while insulin appears not to.
- Empathy talk: Yet again, the Standards take a stab at getting doctors to successfully talk to patients. This time, “new text was added to guide health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style.” Among other items in this section, docs are told that “person with diabetes” is preferred over “diabetic.” And to be nonjudgmental, use language free from stigma, and to impart hope.
- Moving targets: Rather than set specific blood pressure targets, the new Standards recommend an individualized approach, based on cardiovascular risk.
- Nix the e-cigs: Based on new evidence, a recommendation was added discouraging e-cigarette use in youth.
- T2 kids: Speaking of youth, the section on type 2 in kiddos has been “significantly” expanded.
- Easing up on geriatrics: And lastly, for elders, “de-intensification” and “simplification” are now the watch words, complete with a complex flow chart on how to simplify the treatment process.
A Living Document
As in recent years, the online version of the Standards is a “living” document, and will be updated throughout the year as new changes “merit immediate incorporation.”
The world changes quickly.
Speaking of the world, the Standards also address the issues of the financial costs of diabetes, to both individuals and to society, by linking the Standards to the ADA’s much-touted Insulin Access and Affordability Working Group findings from June of last year, which reported that between 2002 and 2013, the cost of insulin nearly tripled. The reason for skyrocketing costs? The Group said the reasons were “not entirely clear.” Nice way of avoiding the term greed, don’t you think?
But in fairness, the Group did an excellent detailed analysis of the complexity of the insulin supply chain. Their final recommendations are largely wishful thinking. Still, at least the ADA’s clout lends legitimacy to discussions of the problems and raises awareness of the issue higher among doctors and perhaps in political circles too.
And adding advocacy to Standards only makes the effort stronger, so this is a change to appreciate.
(HealthDay News) — Patient-centered care is emphasized in updated clinical practice recommendations from the American Diabetes Association 2019 Standards of Care, published as a supplement to the January issue of Diabetes Care.
The Standards of Care include new and revised recommendations for the diagnosis and treatment of children and adults with diabetes. The authors also address strategies to prevent or delay type 2 diabetes, therapeutic approaches, and optimal management.
The 2019 Standards of Care include important updates and changes. These updates include personalizing diabetes care, detailing the need for ongoing assessment and shared decision making, guidance for professionals’ use of language to communicate about diabetes, and a new treatment algorithm that simplifies insulin treatment plans. In addition, the cardiovascular disease management chapter has been endorsed by the American College of Cardiology and includes information on the use of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists that have proven cardiovascular benefit for people with type 2 diabetes and diagnosed cardiovascular disease. A new section focusing on technology and diabetes includes new recommendations for insulin delivery systems and automated insulin delivery devices, as well as discussion of telemedicine for increasing access to care.
“The new 2019 Standards of Care emphasize a patient-centered approach that considers the multiple health and life factors of each person living with diabetes,” William T. Cefalu, MD, from the American Diabetes Association, said in a statement.
Standards of Medical Care in Diabetes—2019Diabetes Care 2019 Jan; 42 (Supplement 1): S1-S2. Diab Care. DOI:10.2337/dc19-Sint01
American Diabetes Association Releases 2019 Standards of Care
January 7, 2019
If you’re living with diabetes, you’re better off if you regularly communicate with your doctor not only about your A1C, but also about things like your mental health and your blood pressure. That’s one of the most significant takeaways from new guidelines released by the American Diabetes Association (ADA), experts say.
The ADA’s Standards of Medical Care in Diabetes—2019, which were published in the January 2019 edition of Diabetes Care, include several guidelines aimed at bringing you into the conversation with your doctor in an effort to improve your health and quality of life.
“This is really a paradigm shift in that we want the patient to participate,” says William T. Cefalu, MD, chief scientific, medical and mission officer at the ADA. “We want an educated patient. We want dialogue between the provider and the patient.”
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What Are the ADA Standards of Care and Why Should You Care?
The ADA issues its Standards of Care report each year to reflect scientific advances in treating diabetes. The recommendations emerge from evidence-based research on the diagnosis and treatment of children and adults with type 1 diabetes, type 2 diabetes, or gestational diabetes. The report also includes strategies to prevent or delay type 2 diabetes, and therapeutic approaches for reducing type 2 diabetes-related complications and helping improve health outcomes.
A committee of 15 leading U.S. experts in the field of diabetes care wrote the documents. That team includes physicians, certified diabetes educators, registered dietitians, and other professionals in the fields of adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning, and pregnancy care. This year, two representatives from the American College of Cardiology (ACC) reviewed, provided feedback, and endorsed the recommendations for heart disease and risk management on behalf of the ACC.
An online version of the Standards of Care, called the Living Standards of Care, will continue to be updated in real time throughout 2019 if new evidence or regulatory changes merit immediate incorporation.
“In 1989, the entire Standards of Care was about four pages. This year, it’s about 200 pages,” Dr. Cefalu says. “The evidence is coming in so quickly, you can’t wait a year to update it. Instead of waiting a whole year, we’ve gone to a system where we can constantly update with new information.”
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An Overview of the Main Tenets of the 2019 ADA Standards of Care
Here are some of the major changes and takeaways from the new report:
An Emphasis on Protecting Heart Health in People With Diabetes
The 2019 Standards of Care considers the multiple health and lifestyle factors of each person living with diabetes. For the first time, the ADA collaborated with the American College of Cardiology to ensure that the ADA’s recommendations are in sync with heart health guidelines. The Standards of Care also supports the ADA’s new Know Diabetes by Heart initiative, a collaboration with the American Heart Association. These efforts are meant to reduce deaths from cardiovascular disease, which is the leading cause of death for people living with diabetes, according to the ADA. According to the Centers for Disease Control and Prevention (CDC), people with type 2 diabetes are twice as likely to die of heart disease as people without the disease.
For patients, this guideline means talking to their endocrinologist, certified diabetes educator, and others involved in diabetes care about heart health, too.
“We are in a partnership with American Heart Association to educate the patient on cardiovascular disease,” Cefalu says. “We want the patient to be educated and discuss this with their physicians.”
RELATED: How Diabetes and Heart Disease Are Connected
The guidelines update the recommendations on which drugs most benefit people who have both diabetes and cardiovascular disease. This includes sodium-glucose cotransporter 2 (SGLT-2) inhibitors, such as Farxiga (dapagliflozin), and glucagon-like peptide 1 (GLP-1) receptor agonists, such as Ozempic (semaglutide).
“The drug treatment approach really differs on whether someone has cardiovascular disease or not,” says Robert A. Gabbay, MD, PhD, chief medical officer of the Joslin Diabetes Center in Boston. “There are now drugs for people with cardiovascular disease that not only reduce blood sugar but reduce death from cardiovascular disease. The ADA has said: The first thing you need to know is whether the patient has cardiovascular disease or not.”
More Personalized Diabetes Care
The new guidelines recommend that people living with diabetes have ongoing assessments and work with their doctors to make choices about their care. The document contains a Goals of Care chart that shows the range of topics you can discuss with your doctor, depending on your needs.
“We’re putting the patient at the center of treatment,” Cefalu says. “Instead of just managing complications, we’ve put in, for the first time, quality of life. We look at things like motivation and depression and put things in a socioeconomic context. If a patient can’t afford the most expensive medication, why prescribe it? There is shared decision making with the patient.”
Studies show that patients adhere better to treatment plans if they participate in selecting treatments and strategies, Dr. Gabbay says.
“Diabetes is not simple,” he says. “Because of that, there are a lot of decisions that have to be made. The question is: How does one do that? It has to be patient-centered, meaning there is a shared decision-making process.”
It’s important for healthcare professionals to use language that patients can understand, Cefalu adds.
“The first thing is to provide awareness that the provider and patient need to be speaking the same language.”
The updated guidelines also include a section on nutrition and physical activity for people ages 65 and older. The document also includes information to help simplify medication in older adults.
Likewise, the guidelines include recommendations for children and adolescents with type 2 diabetes that incorporate the ADA’s guidance on youth statement, which was published in December 2018 in Diabetes Care. These recommendations now include a comprehensive plan for children and adolescents regarding screening, diagnosis, lifestyle management, treatment, heart health, obesity, and psychosocial factors affecting youths with the disorder.
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A Focus on Developing Personalized Diabetes Diets
No single style of eating is “right” for every person with diabetes, according to the new guidelines. A variety of eating patterns can be used to manage diabetes, and the new guidelines suggest that people with diabetes be referred to a registered dietitian for assistance in creating a personalized nutrition plan.
“The Standards of Care includes the latest on nutrition,” Cefalu says. “There is not one diet for all individuals with diabetes. It’s an individualized approach.”
Research suggests that there isn’t much difference between some of the medically acceptable diets, Gabby says. What matters more is whether a person with diabetes can stay on the diet and make long-term lifestyle changes.
“What we have come to realize, in terms of lifestyle changes, is that one size doesn’t fit all,” he says. “In my practice, I ask patients, ‘What have you been successful at in the past?’ That’s probably as good an indicator as anything else.”
The new guidelines also stress the benefits of drinking more water and cutting back on sweetened beverages, including drinks containing noncaloric sweeteners.
RELATED: Going Low-Carb for Type 2 Diabetes Management: Is Keto, Paleo, or Atkins Best?
Recognizing the Role of Technology in Diabetes Management
Technological innovations are shaping the way people manage diabetes, experts say. The 2019 guidelines provide expanded information on a variety of new syringes, pens, insulin pumps, blood glucose meters, continuous glucose monitors, and automated insulin delivery devices to guide patients who are interested in these products.
“This is probably the most rapidly advancing area,” Cefalu says. “Continuous glucose monitoring, especially for type 1 diabetes, has really revolutionized care.”
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How People Living With Diabetes Can Take Advantage of the New ADA Guidelines
Although healthcare professionals use the guidelines to manage care, the updates are meant to benefit those managing diabetes, and these people should be aware of the changes, Cefalu says. An abridged Standards of Care is available to the public on the ADA website.
People with diabetes can also receive information about the guidelines in diabetes classes and support groups, he says. “We have many consumer programs. Our Standards of Care is the backbone of what we do. This information is disseminated in many, if not most, of our patient information groups,” including the free Living With Type 2 Diabetes Program.
Above all, the guidelines encourage people with diabetes to ask questions and feel comfortable discussing a range of issues with their healthcare providers, including problems adhering to diabetes treatment, depression, and the costs of care.
“They should advocate for themselves,” Gabbay says. “One of the simplest ways is asking a lot of questions. If a doctor says, we should start you on this drug, the patient can ask ‘What are the advantages of this drug and are there other drugs?’”
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People managing diabetes can stay engaged in their care in other ways, he says, such as keeping track of annual screenings, like eye exams or foot exams.
They should educate themselves about diabetes, Gabbay adds.
“One of the most powerful things for people with diabetes is to be knowledgeable about diabetes and how to best manage their disease,” says Gabbay. “It is a fundamentally a disease that is self-managed. Talk with your provider about strategies.”
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