The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) have updated their Comprehensive Type 2 Diabetes Management Algorithm and Executive Summary to incorporate newly approved therapies as well as to reflect important research in diabetes care. In 2016, AACE/ACE made several changes.
“The 2016 edition of the comprehensive type 2 diabetes management algorithm added a panel on specific guidance for lifestyle modifications — the cornerstone of therapy for diabetes and metabolic syndrome,” said AACE President and Endocrinology Advisor Editorial Board member George Grunberger, MD.
The revised algorithm, which was published online January 5, 2016, also includes a lipid algorithm, a complications-centric model for treating overweight and obesity, and an updated hierarchy of choices and safety information for the various classes of diabetes medications.
According to Dr Grunberger, who is also a clinical professor in internal medicine and molecular medicine and genetics at Wayne State University School of Medicine in Detroit, Michigan, the new algorithm offers an updated practical guide for all clinicians who manage patients with prediabetes, overweight, obesity, type 2 diabetes, hypertension, and dyslipidemia — conditions that affect a significant portion of the population in the United States.
“It is hoped the algorithm can help decrease the incredible toll these diseases place on patients, their families, their employers, and the entire society,” he said.
Lifestyle Therapy Optimization
The 2016 algorithm considers new therapies, disease management approaches, and key clinical data in a new section on lifestyle therapy optimization.1
Lifestyle therapy should begin with nutrition counseling and education, according to the algorithm, and all patients should strive to attain and maintain an optimal weight through a primarily plant-based diet high in polyunsaturated and monounsaturated fats. Limiting intake of saturated fatty acids and avoiding all trans fats are also recommended. For patients who are overweight or obese, caloric intake should be restricted with the goal of decreasing body weight by 5% to 10%.1
The AACE/ACE task force charged with updating the algorithm suggests that a clinician, dietitian, or nutritionist discuss these recommendations in plain language with patients as well as healthy food selection, meal-planning, grocery shopping, and dining-out strategies. Additionally, patients with diabetes should be educated on medical nutrition therapy to emphasize the need for consistency in daily carbohydrate intake, limiting foods high in sugar, and how to adjust insulin doses accordingly.
Structured counseling and meal-replacement programs appear to be more effective than standard in-office counseling, according to the algorithm.
The task force also highlights the importance of physical activity in the 2016 algorithm. Regimens should be comprised of 150 minutes per week of moderate-intensity exercise such as brisk walking and strength training. Structured programs are beneficial, they note, and implementation should account for the goals and limitations of the individual patient.
Additionally, the algorithm addresses other lifestyle factors that affect diabetes care, including getting enough sleep (approximately 7 hours per night), behavioral support, psychological assessment to monitor for anxiety or depression, and smoking cessation.
Evaluating Treatment for Obesity
The AACE/ACE task force recommends weight loss for all overweight or obese patients with prediabetes or type 2 diabetes. However, the AACE Obesity Treatment Algorithm favors a complications-centric vs BMI-centric approach to treatment.
“The patients who will benefit most from medical and surgical intervention have obesity-related comorbidities that can be classified into 2 general categories: insulin resistance/cardiometabolic disease and biomechanical consequences of excess body weight,” the task force wrote in the Executive Summary for the algorithm.