The American Diabetes Association (ADA) released the 2017 Standards of Medical Care in Diabetes,1 which provide critical new evidence-based additions highlighting the need for individualized care, expanding the role of physical fitness and quality sleep, recognizing the beneficial impact of metabolic surgery, and focusing on hypoglycemia, as well as attention to affordability of care, as published in Diabetes Care.
"The most important concept in diabetes care is individualized care, and the 2017 standards expand on several aspects of how to tailor care to each individual patient," Tamara Darsow, PhD, interim chief scientific and medical officer for the ADA and vice president of research programs and outcomes research told EndocrineWeb. The new standards include recommendations for psychological health, access to care, new expanded and personalized treatment options that consider patient affordability and tracking of hypoglycemia.1,2
For primary care providers (PCPs), said Dr. Darsow, the message is to consider the patient's whole health needs to ensure optimal outcomes. To help, the standards have guidance on issues ranging from sleep disorders to obesity management and affordability of treatments.
New, also, is a report in the standards on the differentiation of diabetes, which outlines a framework for staging diabetes to better enable clinicians to create a tailored, individual approach to care,2 said Dr. Darsow. For example, in type 1 diabetes, autoimmunity, defined as the persistence of 2 or more autoantibodies, accurately predicts the onset of hyperglycemia in people who are in the process of developing diabetes. As a result, the updated standards recommend that persistent autoimmunity is adopted as an earlier clinical diagnosis of type 1 diabetes.1,2
There is additional guidance on when PCPs should refer patients to specialists. There have long been recommendations on referring for kidney, foot and eye problems, said Dr. Darsow. Now, the standards have information on when to refer for obesity management, mental health issues, and sleep disorders,1 she said.
Endocrinologists will find expanded algorithms for type 2 diabetes and insulin use, and a new table has information on medication costs.1,2
There is a welcome focus on obesity as a distinct disease necessitating treatment, according to Caroline Apovian, MD, professor of medicine and pediatrics at Boston University School of Medicine, and director of nutrition and weight management at Boston Medical Center, who reviewed the new standards for EndocrineWeb.
"It looks like their changes revolve around the premise that obesity and lifestyle, for the most part, cause type 2 diabetes (T2D) in this country," said Dr. Apovian. This acknowledgment is the biggest change, and a welcome one.
It reflects a falling in line with what other organizations, including the Endocrine Society and the American Medical Association, have been recommending, that obesity needs to be treated as a distinct disease. In 2015, for instance, Endocrine Society guidelines, which Dr. Apovian co-authored, encouraged the use of alternative diabetes medicines that would be more weight-friendly.
"Now ADA is doing something similar," she said of the attention to weight management. "It doesn't help to just treat the blood sugar and the hemoglobin A1C, especially if the patient isn't managing her weight," she says. "The changes [in the standards] reflect all of that."
Dr. Apovian also applauded the recommendation to assess patients who are obese and heading toward or already struggling with diabetes as candidates for metabolic surgery.1 She said that the reluctance of physicians to refer patients who are eligible for bariatric surgery is disturbing given the evidence of its efficacy in reversing diabetes.
“Some patients don't want the surgery,” she told EndocrineWeb, "They think obesity is under their control," despite the evolving medical view that it is a chronic disease.
The 2017 standards of medical care include guidelines on eligibility for bariatric or metabolic surgery that have been expanded to include a lower body mass index (BMI of 30 rather than 40 in patients with inadequately controlled T2D.1
Her bottom line? "We are finally realizing obesity needs to be treated to avoid the likelihood that the patient will develop T2D," said Dr. Apovian, and "We are all now finally focusing on it, and realizing that bariatric surgery can be used as a cure for both [disease]."
Recognizing that many people with diabetes are also diagnosed with cardiovascular disease (CVD) or are at risk for it, the standards highlight studies which demonstrated that empagliflozin and liraglutide can reduce CV events and mortality in patients with diabetes, said Dr. Darsow.
The ADA 2017 standards were developed at a symposium which was supported by an unrestricted educational grant from Novo Nordisk Inc.