COMMENTARY

New ADA Standards: Promoting Health

Anne L. Peters, MD

Disclosures

January 31, 2020

This transcript has been edited for clarity.

Today I'm going to discuss the 2020 American Diabetes Association (ADA) Standards of Medical Care in Diabetes. I was part of the committee that wrote these standards of care. This committee consisted of incredibly hard-working, smart people, and it was an honor to work with them.

We had some hiccups along the way, but we continued to do the best we could with the available evidence to move our standards of care and recommendations forward. The ADA standards don't change significantly from year to year; rather, there are incremental changes based on the evidence.

If you're not familiar with the grading of evidence, level A evidence is the highest-quality data from randomized controlled trials (RCTs) and meta-analyses. Less rigorous evidence is ranked from B to E, with level E evidence being expert opinion—what we experts think is the best way to manage our patients in the absence of RCT data.

As you go through the guidelines, you'll see that the quality of evidence varies. In some areas, we have a lot of evidence, but in other areas—particularly with devices—much of the evidence is level E because it reflects what we've been doing in practice rather than data from RCTs.

Improving Care and Promoting Health

Section 1 is called "Improving Care and Promoting Health in Populations." Fundamentally, if we don't improve care and promote health in large populations, none of what we do matters. I think each of us believes that we can help individual patients quite a lot, but we need to make what we do work across populations. We discuss this in terms of the chronic care model and how we can look at population health.

This year, we specifically talk about the cost of insulin. This is an important topic, because patients are becoming less and less able to afford insulin. I've had patients die because of lack of access to insulin. It's a very serious issue that has gotten a lot of press—they even brought it up in the presidential debates. We all need to be aware that some of our patients may not be able to afford insulin, and if they can't, we need to be able to discuss alternative insulins—for example, the much less expensive NPH and regular insulins.

In this section, we talk about cost, but later in the guidelines we also talk about how to use NPH and regular insulin in our patients. It may not be our first choice, but we need to make it a safe choice, because it's important that we keep our patients alive.

We also discuss the management of migrant and seasonal agricultural workers, because they have special healthcare needs and many of them already have diabetes or may be at risk of developing diabetes.

Classification and Diagnosis of Diabetes

Section 2 discusses the classification and diagnosis of diabetes. I'd love for this section to help me characterize my patients who have adult-onset type 1 diabetes, because none of us know what to call it. Do we call it type 1? Do we call it type 2? Do we call it type 1 that's managed like type 2? Or do we call it type 1.5? Do we call it LADA (latent autoimmune diabetes of the adult)? What do we call an adult who develops diabetes and has positive antibodies and thus positive autoimmunity, many of whom can be handled with some insulin but also other type 2 drugs? These patients are a kind of hybrid who become more like a type 1 (the classic autoimmune type) but still have some features of type 2.

So even though we're not giving you a new category, we do discuss the debate about LADA and how we should think of it in our patients. We still say to diagnose the patient as having type 1 (autoimmune diabetes) versus type 2. But again, it's kind of a spectrum, and clinically, we characterize our patients by what they need and how they respond to various therapies, whether it's insulin with or without noninsulin therapies.

Section 2 also includes much more detail about cystic fibrosis-related diabetes. Patients with cystic fibrosis are living longer and many of them develop diabetes, so we discuss their management. We also added information about pancreatic diabetes or diabetes in the context of endocrine pancreas disorders. These patients are somewhat different from the classic patient with type 1 or type 2 diabetes, but many also have absolute insulin deficiency, so in that way they are similar to someone with type 1. Finally, we discuss the diagnosis of gestational diabetes mellitus.

Facilitating Behavior Change

Section 5, which was formerly "Lifestyle Management," is now called "Facilitating Behavior Change and Well-being to Improve Health Outcomes." In this section, we talk about everything we do to educate the individual to help change habits; deal with current or developing mental health issues; deal with diabetes distress; and all of the psychosocial and educational issues that are vital to helping patients do better, feel better, and achieve better outcomes. We pulled many of these topics from other sections and put them in one area.

Glycemic Targets

Section 6, called "Glycemic Targets," now includes the concept of time in range in the ambulatory glucose profile. It's important that these concepts are known and promoted as a way to interpret data that come from continuous glucose monitoring (CGM). Those of us who frequently use CGM are aware of these concepts, but it's important to encourage the use of CGM in more practice settings and to help providers understand these tools for interpreting the data.

We also talk about the assessment and treatment of hypoglycemia, and the need to test for hypoglycemia unawareness in patients who are on medications that can cause hypoglycemia. We discuss the use of oral treatments for patients who are able to ingest oral carbohydrates, as well as the newer forms of glucagon. We talk a lot about glycemic targets and how we are increasingly looking at them on a more day-to-day basis, looking at such things as time in range in the ambulatory glucose profile.

Diabetes Technology

Diabetes technology (Section 7) is an interesting area because technology is changing so quickly. We don't have a lot of RCT data with regard to technology for a variety of reasons. First, we don't need lots of data for these devices to be approved by the US Food and Drug Administration. Second, changes are happening so quickly that it's really hard to do studies; by the time you get the results, technology has changed.

We did our best to summarize what exists in terms of the literature. And then we made a lot of level E recommendations based on, frankly, how we're using the technology in our own practices. I'm obviously a big fan of technology and I use it often, but it's important to realize that it's all about the patient, as is everything in diabetes management. Some patients readily adopt technology, and others don't. In my practice, I offer patients all the tools and then see when a patient is ready to use which one.

The section is divided into three categories. The first is about self-monitoring of blood glucose. The second is about CGM. And third, we discuss insulin delivery. We tried to include everything that's available now and give recommendations based on what's been published and also based on practice, with the knowledge that there are going to be updates throughout the year as new technologies become available.

This has been the first part of my overview of the ADA 2020 Standards of Medical Care in Diabetes. In my next video, I will discuss the pharmacologic treatment of type 2 diabetes, among other topics.

Anne L. Peters, MD, is a professor of medicine at the University of Southern California (USC) Keck School of Medicine and director of the USC clinical diabetes programs. She has published more than 200 articles, reviews, and abstracts and three books on diabetes, and has been an investigator for more than 40 research studies. She has spoken internationally at over 400 programs and serves on many committees of several professional organizations.

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