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