In the January edition of the American Diabetes Association's flagship professional journal Diabetes Care, the association has issued a document that lays out its wide-ranging official recommendations for diabetes care in the U.S.
This is the ADA's annual update of their Standards of Medical Care in Diabetes, and the 56-page document deals with everything from classifying the various flavors of diabetes to the use of a 128-Hz tuning fork in foot exams. But unlike past years, this latest update also contains some interesting type 1-specific tidbits that caught my eye.
Yes, you read that right: type 1 diabetes, not the other type that we're more used to seeing the ADA issue guidelines on.
There are a number of type 1-focused nuggets in this new document, and one of the most exciting is how the ADA is now putting its money where its mouth is as far as more "personalized patient-centered care." Sure, they claim to be doing the same for type 2 patients, but in that we're focusing on the type 1 aspect, that's what we'll detail for this post.
Type 1 May Be a Family Affair
Remember that Utah family we featured here the other day, with six of their eight kids living with type 1? Well, the ADA is taking notice of this kind of trend.
The ADA's now telling healthcare providers to consider referring relatives of type 1s for antibody testing via clinical studies like TrialNet. The organization feels that there's now sufficient evidence to show that this kind of screening can be an effective "advanced warning system" to lower the risk of life-threatening ketoacidosis-style Emergency Room diagnoses of type 1 diabetes.
Quoting the new Standards: "Such testing, coupled with education about symptoms of diabetes and follow-up in an observational clinical study, may allow earlier identification of onset of type 1 diabetes and lessen presentation with ketoacidosis at time of diagnosis."
And speaking of screening...
More Than Just Diabetes
The 2013 Standards also advise that all type 1 kiddos be screened for celiac disease as soon as possible after diagnosis. The document states that while celiac occurs in less than 1% of the general population, some estimates place the type 1 celiac rate as high as 16%. (Yikes!)
Adults, if not already screened, should also be checked for celiac, as well as other auto immune issues like thyroid and Vitamin B12 deficiency, because of the "increased frequency of other autoimmune diseases in type 1 diabetes."
This is the part where Amy, Mike and I give our thumbs up in agreement, since on top of type 1 diabetes Amy lives with both gluten intolerance and hypothyroidism, while Mike and I with the latter. Oh, the fun times our trio has! It's actually pretty revolutionary that ADA is highlighting the type 1-celiac connection, as just a few short years ago, it was nearly impossible (for Amy and others) to find good resources or HCPs familiar with this unpleasant duo.
Test Strips & Taking on "Payers"
This year's Standards take on health plans in ways both subtle and bold -- most notably for type 1s in the areas of BG test strips and analog insulins.
For many years, the ADA guidelines have stated that PWDs on insulin should test "at least three times a day." Many insurance plans, including Medicare and Medicaid, took this and twisted it to mean a maximum of three tests a day, providing a basis for them to impose strict test-strip rationing that's been getting worse and worse in recent years.
But now, the ADA has fired back with some of the strongest language ever in their guidelines, clearly stating that anyone on a pump or multiple daily injections (MDI): "should do SMBG [Self-Monitoring of Blood Glucose] at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving."
Just to be sure the health plans were listening, the ADA went on and spelled it out with math: "For many patients, this will require testing 6—8 times daily, although individual needs may be greater."
Send cards and flowers to the ADA's new Chief Medical Officer Bob Ratner, who I suspect might have had a hand in this. He's long been critical of health plans "not getting it" that blood sugar testing is the (cheap) key to healthy patients, and that doctors have better things to do with their time than fighting insurance companies all day long for a few meager strips for their patients.
I think with testing volume so clearly spelled out in a respected national Standard of Care, it will be much harder for health plans to deny the coverage of strips as we move forward.
The ADA's Type 1 Playbook
Type 1s should be treated with MDI or pumps, the 2013 Standards say. And we should get modern analog insulin for our pumps, pens, or syringes to reduce hypo risk. And we should be taught how to count carbs. No more sliding scale!
All diabetes should be treated using a chronic care model, with a medical team composed of providers, nurses, dietitians, pharmacists, mental health professionals. Although diabetes educators aren't mentioned in the discussion of care teams, there's plenty of support for the role of the educator in this Standard. It even goes so far as to say education and support is "an integral component of care," and "should be adequately reimbursed by third-party payers."
Equally important, the guidelines lay out the approach that any diabetes educator should NOT take: "Current best practice of DSME [diabetes self-management education] is a skill-based approach that focuses on helping those with diabetes make informed self-management choices. DSME has changed from a didactic approach focusing on providing information to more theoretically-based empowerment models that focus on helping those with diabetes make informed self-management decisions."
Does your CDE empower you, or lecture to you?
On a personal note, I was elated to read this in the ADA document: "There is growing evidence for the role of community health workers and peer and lay leaders in delivering (education and support) in conjunction with the core team." Yay! (This is the model I function under at my day job.) It took the AADE (American Association of Diabetes Educators) quite a long time to address the role of community health workers, and it's great to see ADA recognizing them as well!
A Gold Star for CGM
The new guidelines state that CGM "can be a useful tool to lower A1C" in folks 25 years old and older, and "may be helpful" in children, teens, and young adults. Why the weaker support for CGMs for kiddos? So far, clinical studies haven't shown a robust enough improvement in overall control among youth using CGM, but the ADA points out that "the greatest predictor of A1C lowering...was frequency of sensor use, which was lower in younger age-groups." In other words, if ya' can get the kid to wear the damn thing, it will work.
As with the test strip issue, I think the Standard's support for CGM will help knock down the remaining walls to getting CGMs covered for adult type 1s, and provides at least some ammo to help the parents of type 1 kids.
One Size Doesn't Fit All, After All
After years of promoting a one-size-fits-all A1C target range, and then easing their stance up a bit last year, the ADA has now adopted a flexible target that takes into account the age and overall health of the patient, with higher targets in the 8% range for older or sicker patients, 7-ish for most people, and mid-sixes for the young and otherwise healthy.
In a surprise move, the ADA also raised the blood pressure target from 130/80 to 140/80, stating that there was a lack of evidence that the stricter target had any positive long-term impact on PWD health.
Oh, and just so you don't lose the next time you play Scrabble: "microalbumin" (a measure of kidney health) has been renamed and will henceforth be called "increased urinary albumin excretion," because why use one word when you can use four instead?
Don't Blame the Patient
And in one last refreshing turnaround, the new Standards specifically tell docs to quit blaming their patients when things don't go according to plan. Docs are instead instructed to know that it is their responsibility to re-think barriers to patient success — including income, health literacy, diabetes distress, depression, and competing demands.
WOW. We're seeing a whole new ADA here. I just hope the doctors who treat diabetes will read this new document cover-to-cover and take the advice to heart.
Maybe the ADA can't live up to their motto, Together we CAN Stop Diabetes®, but these new guidelines sure might make living with diabetes a bit easier for ALL of us.