Standards of Care in Diabetes 2016--What's New?
Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE Terminology No longer using the term diabetic.
Diabetes does not define people. People with diabetes are individuals with diabetes, notdiabetics. Diabetic will continue to be used related tocomplications, e.g., diabetic retinopathy. The Association made one point of clarification this year which we hope clinicians, advocates, journalists, and the general public will adopt: In alignment with our longstanding informal policy Association-wide, the Standards of Care will no longer use the term diabetic to refer to patients with diabetes. This decision is in alignment with the American Diabetes Associations position that diabetes does not define people. Those with diabetes are individuals with diabetes, not diabetics. ADA will continue to use the term diabetic as an adjective for complications related to diabetes(e.g., diabetic retinopathy). [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes.Introduction. Diabetes Care 2016; 39 (Suppl. 1): S1-S2 3 Strategies for Improving Care
Section 1. Strategies for Improving Care Therapy must be tailored for patients with: Food insecurity-lack of funds to afford appropriate food Cognitive dysfunction-special consideration HIV- screen for DM prior to starting therapy and annually Cognitive Dysfunction
Intensive glucose control is not advised for theimprovement of poor cognitive function in hyperglycemicindividuals with T2DM. In individuals with poor cognitive function or severehypoglycemia, glycemic therapy should be tailored toavoid significant hypoglycemia. Specific to your patients with cognitive dysfunction, the most common form of which is dementia, including Alzheimers, the Association offers four recommendations: First, intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes, [CLICK] Second, in individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia. [SLIDE[ American Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12 5 Cognitive Dysfunction
In individuals with diabetes at high CVD risk, thecardiovascular benefits of statin therapy outweigh therisk of cognitive dysfunction. If a second-generation antipsychotic medication isprescribed, changes in weight, glycemic control, andcholesterol levels, should be carefully monitored and thetreatment regimen reassessed. In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction [CLICK] And, finally, if a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels, should be carefully monitored and the treatment regimen reassessed. [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes.Strategies for improving diabetes care. Diabetes Care 2016; 39 (Suppl. 1): S6-S12 6 Section 2. Classification and Diagnosis of Diabetes
None of the test used for diagnosis are preferred over the other. All persons over age of 45 should be tested regardless of weight. Adults who are obese with one or more risk factors should be tested regardless of age. Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG) 126 mg/dL (7.0 mmol/L) OR 2-h plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT A1C 6.5% Random plasma glucose200 mg/dL (11.1 mmol/L) The same tests are used to screen for and diagnose diabetes and to detect people with prediabetes. These include: Fasting plasma glucose (FPG) 126 mg/dL OR 2-hour plasma glucose 200 mg/dL during an OGTT A1C 6.5% Or in a patient with classic symptoms of hyperglycemia a random plasma glucose 200 can also be used. The subsequent slides examine each of the criteria in greater detail. [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 Reference American Diabetes Association. Standards of medical care in diabetes2014. Diabetes Care 2014;37(suppl 1):S15; Table 2 8 POC testing not recommended
A1C 6.5% * Performed in a laboratory using a method thatis NGSP certified and standardized to theDCCT assay POC testing not recommended Greater convenience, preanalytical stability,and less day-to-day perturbations than FPGand OGTT Consider cost, age, race/ethnicity, anemia, etc. One way to combat both of those issues is with the A1C. This test should be performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay[CLICK] Although point-of-care (POC) assays may be NGSP-certified, proficiency testing is not mandated for performing the test, so use of these assays for diagnostic purposes may be problematic [CLICK] The A1C has several advantages to the FPG and OGTT, including greater convenience (fasting not required), possibly greater preanalytical stability, and less day-to-day perturbations during periods of stress and illness[CLICK] But, these advantages must be balanced by greater cost, the limited availability of A1C testing in certain regions of the developing world, and the incomplete correlation between A1C and average glucose in certain individuals [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes.Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22 References International Expert Committee: International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:13271334 American Diabetes Association. Standards of medical care in diabetes2014. Diabetes Care 2014;37(suppl 1):S15; Table 2 Ziemer DC, Kolm P, Weintraub WS, et al. Glucose-independent, black-white differences in hemoglobin A1c levels: a cross-sectional analysis of 2 studies. Ann Intern Med 2010;152:770777 Kumar PR, Bhansali A, Ravikiran M, et al. Utility of glycated hemoglobin in diagnosing type 2 diabetes mellitus: a community-based study. J Clin Endocrinol Metab 2010;95:28322835 9 Self Management Education Nutrition Counseling Physical Activity
Foundations of Care Self Management Education Nutrition Counseling Physical Activity Smoking Cessation Immunizations Psychosocial Care Medications The foundations of care include eight key components: Self-management education, nutrition, counseling, physical activity, smoking cessation, immunizations, psychosocial care, and medications, which are covered in other chapters. [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 10 Recommendations: Physical Activity
Children with diabetes/pre-diabetes: at least 60 min/dayphysical activity Adults with diabetes: at least 150 min/wk of moderate- intensity aerobic activity over at least 3 days/week withno more than 2 consecutive days without exercise All individuals, including those with diabetes, shouldreduce sedentary time, particularly by breaking upextended amounts of time (>90 min) spent sitting. Adults with type 2 diabetes should perform resistancetraining at least twice weekly Recommendations for physical activity for people with diabetes1 are summarized on this slide As with all children, children with diabetes or prediabetes should be encouraged to engage in at least 60 minutes of physical activity each day.[CLICK] Adults with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (with moderate defined as 5070% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. [CLICK] All individuals, including those with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting. [CLICK] And finally, in the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. [CLICK] [SLIDE] American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2016; 39 (Suppl. 1): S23-S35 References American Diabetes Association. Standards of medical care in diabetes2014. Diabetes Care 2014;37(suppl 1):S31 Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393403 Tuomilehto J, Lindstrm J, Eriksson JG, et al.; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:13431350 Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537544 Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes. The American Collegoe of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010;33:26922696 11 Section 4. Prevention or Delay of Type 2 Diabetes
Refer those with pre-diabetes to intensive diet and physical activity behavioral counseling program (lose 7% weight and increase moderate-intensity PA to at least 150 min/week Follow up counseling and maintenance programs long term Diabetes prevention programs should be covered by third party payers Metformin therapy for prevention should be considered in those with pre-diabetes, especially those with BMI greater 35 kg/m2, those less than 60 years and women with prior gestational diabetes mellitus Diet, physical activity, and behavioral therapy
Diabetes Care Vol 39, Supp 1, Jan 2016 Table 6.1Treatment for overweight and obesityin type 2 diabetes BMI category (kg/m2) Treatment 23.0* or25.026.9 27.0 29.9 30.0 34.9 35.0 39.9 $40 Diet, physical activity,and behavioral therapy Pharmacotherapy Bariatric surgery Section 4. Prevention or Delay of Type 2 Diabetes
Annual monitoring for development of diabetes Screening for and treatment of modifiable risk factors for CVD DSME programs are appropriate venues for those with prediabetes to receive education and support NEW technology assisted tools including internet based social networks, distance learning, DVD-based content, and mobile applications can be useful for lifestyle modification to prevent diabetes Some supportive apps Myfitnesspal more specific to calorie counting
American Diabetes Association Standards of Care Medtronic Carb Counting with Lenny AADE Diabetes Goal Tracker Some are free and others range from $ $9.99 Section 5. Glycemic Targets
Methods for assessing glycemic control SMBG A1c *CGM could be useful addition Mean Glucose Levels for Specified A1C Levels
Mean Glucose Mean Plasma Glucose* Fasting Premeal Postmeal Bedtime A1C% mg/dL mmol/L 6 126 7.0