COMMENTARY

What's New in the 2019 Standards of Medical Care in Diabetes

Anne L. Peters, MD

Disclosures

February 07, 2019

This transcript has been edited for clarity.

Every year, the American Diabetes Association (ADA) updates its standards of medical care[1] for people with diabetes. Let's discuss what's new and interesting this year.

Improving Care With Telemedicine

Section 1 focuses on improving healthcare in populations. One of the recommendations I personally like is the discussion of telemedicine. In many places, telemedicine is not well funded. I think it's a great idea for our patients with diabetes because it allows us to reach out to them between in-person clinic visits.

Much of diabetes care doesn't involve face-to-face interactions with a patient in terms of doing a physical exam but rather involves discussing values from their meters or sensors. Telemedicine is a great way to go when it comes to managing our patients with diabetes, and I'm hopeful that it will become something that's done more commonly.

A One-Stop Diagnosis

Section 2 is about the classification and diagnosis of diabetes. Previous recommendations suggested that we diagnose diabetes on the basis of blood samples that were taken a week or two apart. You would check the blood glucose level, and if it was high, you would check it a second time to validate the first abnormal finding.

Now, we can make the diagnosis of diabetes on the basis of two abnormal results from the same blood sample. We can measure a fasting glucose level and an A1c level at the same visit, and if both are elevated, make the diagnosis of diabetes.

The Physical Exam and Evaluation

This section is called "Comprehensive Medical Evaluation and Assessment of Comorbidities," and it's one that everyone needs to know about. What is most important in this section are the tables, which show what is expected in a basic physical examination and evaluation—the lab tests we should be conducting, the frequency of testing, and the assessment and planning with the patient.

Each of these units discusses patient engagement with the standards of care, so that the patient and physician can be on the same page. A new table lists the risks of treatment-associated hypoglycemia, which is useful to review because we all use many different medications in our patients with diabetes.

Finally, the standards recommend that we use the 10-year atherosclerotic cardiovascular risk tool as a part of the patient assessment to calculate the patient's 10-year risk for a cardiovascular event.

Customized Lifestyle Management

Section 5 is about lifestyle management. Many things are discussed in this section, but the bottom line is that there is no one-size-fits-all, best lifestyle approach for patients with diabetes. The key is that we customize the approach. Talk to the patient, determine what's best for the individual, and then work with the patient to be successful with that approach.

A recommendation that stood out to me is one stating that patients not only consume fewer sugar-sweetened beverages but also fewer nonnutritive sweetened beverages. Basically, the ADA standards recommend that patients drink a lot of water, which is a very good idea. Remember, it's both full-on [cola] and [diet cola] that patients should avoid in lieu of drinking water.

Diabetes Technology and Patient Education

Section 7 is about diabetes technology. This is an entirely new section that tries to cover everything related to technology, from insulin syringes and pens, to self-monitoring of blood glucose, to pumps and sensors.

There are a couple of important takeaways. Throughout this section is the emphasis that education is key, that you can't just give a patient a device and expect them to be successful. Instead, the devices need to be used with an integrated education program and integrated clinical care.

Self-monitoring of blood glucose levels is obviously important for patients who are taking insulin, but these standards say that patients who are doing well on oral agents and aren't having any issues, especially with hypoglycemia, and are followed in routine care may not need to self-monitor blood glucose levels. When people do monitor—and there are patients who love to get the feedback about their levels—that data should be used to educate the patient and integrate the care plan.

This section covers a lot about using pumps and sensors in people with type 1 diabetes. People with type 1 diabetes should be able to use either a pump or multiple daily insulin injection regimens, depending on the patient's preference, and should have access to continuous glucose monitoring technology. The data are less strong in patients with type 2 diabetes, but those with type 2 diabetes who are on insulin may benefit from continuous glucose monitoring.

Section 8 discusses obesity. There are no big changes here, although the ADA standards align the recommendations for metabolic surgery with recent guidelines.

Section 9 is on the pharmacologic therapy of people with type 2 diabetes. This section reviews all of the newly released ADA/EASD (European Association for the Study of Diabetes) guidelines. I definitely recommend that you become familiar with them, because it's a very important part of how we approach our patients and the treatment for their type 2 diabetes.

Cardiovascular Disease and Microvascular Complications

Section 10 discusses cardiovascular disease and risk management. For the first time, this section has been endorsed by the American College of Cardiology. I strongly believe that it's important that all of the major healthcare organizations begin to agree on these guidelines.

I don't think it helps to have one group saying one thing and another group saying another, so this is very good news. This section discusses more about the treatment and evaluation of congestive heart failure and provides new information about aspirin use.

Section 11 covers microvascular complications and foot care. The standards discuss using telemedicine for retinal screening and suggest that the previously recommended foot inspections at every visit are needed only for patients with high-risk feet.

Annual foot inspections are considered necessary for everyone, but taking off shoes and socks to look at the feet at every single visit is only needed for patients with high-risk feet or those who have concerns about something going on with their feet.

Elderly Patients

Finally, section 12 is on older adults. I like this section quite a lot because it clarifies many things that haven't been well defined. Included are comprehensive tables and discussions about how to categorize the risk of a patient who is older, and how to categorize benefit in terms of better glycemic control.

We all see patients who are 80 years old. Some may have 10 or 15 more years of life left and some may not have many years left. This section goes through how to look at the human being in front of you—at their comorbidities, life expectations, and risks—and the benefits of various blood glucose levels and A1c targets, and how to use those in clinical practice.

It includes a table about deintensifying insulin therapy. I've never seen this table before, and I absolutely love it. We all have patients who come in on complex insulin regimens; this table shows how to make it easier. This is very important when treating our older population, especially as they may have a bit of dementia and issues with managing their diabetes.

Those are a few of the key changes in the new edition of the diabetes standards of care. I encourage you to read as much of the document that interests you, but do look at the section on the assessment and evaluation of our patients, as well as the treatment guidelines for patients with type 2 diabetes. If you're familiar with those things and share them with your colleagues, it will help improve the lives of your patients with diabetes.

Thank you.

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