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.