The American Diabetes Association’s 2016 Standards of Medical Care in Diabetes include several significant updates, most notably recommendations for the management of obesity for treatment of type 2 diabetes, changes regarding heart disease, and differences in care for various patient populations.
The guidelines, which were released online December 22, 2015, will be published in a supplement to the January issue of Diabetes Care.
In addition to recommendations regarding obesity, heart disease, and care of different patient populations, the updated guidelines address new general treatment goals as well as new tools for evaluating quality of care.
The guidelines also suggest tailoring diabetes treatment to improve care among vulnerable populations. They provide clinicians with guidance on treating ethnic, cultural, gender, and socioeconomic differences and disparities. Additionally, strategies for addressing food insecurity, cognitive dysfunction, mental illness, and patients with HIV who also have diabetes are included in the 2016 Standards.
A Focus on Obesity
The revised Standards of Care include a tiered approach to obesity management, including lifestyle intervention, pharmacotherapy, and bariatric surgery. There is also a new section devoted to the medical and surgical management of individuals with diabetes.
“This new section incorporates prior recommendations related to bariatric surgery and provides new recommendations for a thorough assessment of weight in diabetes,” said Jane Chiang, MD, senior vice president of the American Diabetes Association (ADA). “We address treating overweight/obesity with behavior changes and pharmacotherapy. This section also has a new table of approved medications for the long-term treatment of obesity.”
Specific recommendations suggest that overweight and obese patients aim to achieve 5% weight loss. Interventions should be high intensity, including at least 16 sessions over 6 months, and focus on diet, physical activity, and behavioral strategies to achieve a 500 kcal to 750 kcal/day energy deficit. Diets that vary in protein, carbohydrate, and fat content that provide the same caloric restriction are equally effective, according to the guidelines.
The Standards also offer guidance on maintaining weight loss in the long term as well as how to incorporate high-intensity interventions to achieve more than 5% weight loss in certain patients.
Recommendations regarding pharmacotherapy for weight loss suggest careful consideration of benefits and risks, minimizing medications for comorbid conditions that are associated with weight gain, and discontinuation of weight-loss medications if less than 5% weight loss is achieved after 3 months.
In terms of surgical management, the 2016 Standards state that bariatric surgery may be considered in adults with a BMI greater than 35 kg/m2 and type 2 diabetes, particularly if the disease or its associated comorbidities do not respond well to lifestyle and pharmacological interventions. However, current evidence is not sufficient to recommend bariatric surgery in patients with a BMI of 35 kg/m2 or less.
Updated Recommendations on Heart Disease in Diabetes
The new guidelines also tackle heart disease, with the ADA updating its atherosclerotic cardiovascular disease (ASCVD) recommendations. They call for clinicians to consider prescribing aspirin therapy to women aged 50 and older who have at least 1 additional major risk factor, such as family history of premature ASCVD, hypertension, smoking, dyslipidemia, or albuminuria.
“Atherosclerotic cardiovascular disease replaced cardiovascular disease since ASCVD is a more specific term,” said William Herman, MD, MPH, professor of medicine and epidemiology at the University of Michigan and chair of the ADA’s Professional Practice Committee.
“We added a pharmacologic section for treating people older than 75 years. We changed the age for the aspirin recommendation for women; we decreased the age at which aspirin should be considered for women from age older than 60 years to age older than 50 years since recent evidence showed that aspirin would benefit younger women,” he added.
Another significant change involved the agent ezetimibe (Zetia, Merck). The medication was not previously recommended, but now the guidelines state it may provide additional cardiovascular benefits for select individuals with diabetes.
“We added information about the use of ezetimibe due to the IMPROVE-IT trial results. We stated that adding ezetimibe to a moderate-intensity statin may provide additional cardiovascular benefits for certain individuals with diabetes,” Dr Herman said in an interview with Endocrinology Advisor.
“In the 2015 Standards, we did not recommend considering the use of ezetimibe. We also included a new table that provides efficacy and dosing details for high- and moderate-intensity statin use.”
Role of Novel Technology
The ADA recognizes the important role of new technology in managing diabetes, guideline authors noted. For instance, one new recommendation states that people who use continuous glucose monitoring (CGM) and insulin pumps should have continuous access after age 65. People at risk for developing type 2 diabetes should also consider the use of new technologies, such as Internet-based social networks, distance learning, and mobile applications, to effectively modify behaviors for prevention of diabetes.
“Technology has been beneficial for those requiring intensive insulin therapy, particularly those with difficulty perceiving or treating hypoglycemia,” said Robert Ratner, MD, chief scientific and medical officer of the ADA.
“The use of continuous subcutaneous insulin infusion systems (insulin pumps), CGM, and the recently approved linked systems, including low glucose suspend features, provide added safety. We recognize their value and the aging of the diabetes population to recommend continued access for those people with diabetes aging into the Medicare system at age 65,” he noted.
Addressing Social Issues
Diabetes management requires individualized, patient-centered, and culturally appropriate strategies, according to Dr Chiang. She noted that the 2016 Standards’ new obesity management and vulnerable population sections are 2 examples where individualized care is essential.
“We realize that people with diabetes also struggle with social issues. So, we have included recommendations for those with food insecurity (inability to get nutritious food), cognitive dysfunction and/or mental illness, and HIV,” Dr Chiang told Endocrinology Advisor. “We also highlight the disparities related to ethnicity, culture, sex, and socioeconomic differences. For optimal success, we emphasize that diabetes care must integrate all aspects of the individual’s life.”
Hyperglycemia is more common in those with diabetes and food insecurity, the authors noted in the guidelines. They state that the steady consumption of carbohydrate-rich processed foods, binge eating, and nonadherence to diabetes medications owing to financial constraint also complicate diabetes management.
Furthermore, studies suggest that anxiety and depression can lead to poor diabetes self-care behaviors. The guidelines state that clinicians need be well-versed in these risk factors for hyperglycemia and take practical steps to alleviate these issues to improve glucose control.
Other updates to the 2016 Standards include expanding the scope for treating different populations with diabetes. New recommendations address diabetes self-management education and support, psychosocial issues, and treatment for youth with type 2 diabetes. An in-depth section on older adults provides a framework for treatment based on cognitive impairment, coexisting chronic illnesses, and functional status.
For women of child-bearing age, there are new recommendations on pre-gestational diabetes, gestational diabetes, and diabetes management during pregnancy.
Racial, Ethnic, and Socioeconomic Concerns
Recent epidemiologic data show that risk for diabetes and its complications differ by racial, ethnic, and socioeconomic status, according to Dr Ratner.
“We point these out in an attempt to rectify them moving forward,” he said.
“For example, Asian Americans are prone to type 2 diabetes at a BMI greater than 23 kg/m2, whereas other groups only begin to see an increase at 25 kg/m2. In addition, African Americans with diabetes are more prone to hypertension and diabetic kidney disease than other ethnic groups and should receive more aggressive screening and intervention,” Dr Ratner told Endocrinology Advisor.
“Ultimately, we are emphasizing the patient-centered approach to diabetes management, meeting the specific needs of the person with diabetes.”
Intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes, Dr Ratner noted. The guidelines state in individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia.
The guidelines also address patients with HIV. They note that these patients should be screened for diabetes and prediabetes using a fasting glucose level before starting antiretroviral therapy. The recommendations also include re-screening these patients 3 months after starting or changing antiretroviral therapy. If initial screening results are normal in patients with HIV, then checking fasting glucose each year is adequate, according to the guidelines.
Individuals with diabetes and their families and health care providers are constantly challenged to achieve diabetes treatment goals, according to Dr Herman. He said the Standards of Care cohesively outline goals for effective diabetes treatment in one place and as a result make diabetes management more accessible.