It’s that time of year again. No, not post-holiday clearance sales. Not New Year’s resolution regrets. Not taxes. (Even though all those things are happening). No, we’re talking about the annual diabetes tradition from the American Diabetes Association (ADA): They have released their updated Standards of Medical Care for those of us with diabetes. All 159 pages of them.
Why does this matter? Because, like EF Hutton, when the ADA talks, people listen. Well… at least doctors do. So if the ADA changes something, like say dropping the decades-old advice that all PWDs take a daily aspirin—which they did a number of years ago—your treatment will likely change. The Standards also have an impact on health policy and insurance coverage, so we are well-advised to pay attention.
What’s new in this year’s Standards? Anything shocking?
Well, there’s no reason to stop the presses, but there is some interesting stuff this year. Among other things, the ADA has a new focus on technology, wants us in no uncertain terms to pay attention to our hearts, and advises us to drink more water. On the bright side, you can leave your shoes on at the endo's office and put salt on your French fries again. And some of you can throw your meters in the trash. Oh, and like in the rest of the medical world, there’s an expansion of focus on the buzz-happy notion of "patient-centered medicine," and a new primer for teaching doctors how to talk to patients. Again.
A New Focus on Tech
The biggest change in the Standards this year is the addition of a whole new section: D-tech now has its very own independent segment in the Standards, set to include recommendations on meters, CGMs, insulin delivery devices, and more. Quoting the Standards document, “The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge… To that end, the ‘Standards of Medical Care in Diabetes’ (Standards of Care) now includes a dedicated section on Diabetes Technology, which contains preexisting material that was previously in other sections that has been consolidated, as well as new recommendations.”
In its first time out of the gate, the new tech section of the Standards is focused solely on insulin delivery and glucose monitoring, but we are promised that in future years: “this section will be expanded to include software as a medical device, privacy, cost, technology-enabled diabetes education and support, telemedicine, and other issues that providers and patients encounter with the use of technology in modern diabetes care.”
Anything interesting in there? The ADA likes CGM and new "flash" (intermittently scanned) meters, and is excited about the future potential of automated insulin delivery. But for the first time, the org has begun to question the use of the old-fashioned fingerstick for PWDs not on insulin, stating, “The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population.” Which makes sense, given that most insurance companies will only give this population one strip per day, although the ADA did point to a study by Dr. William Polonsky showing that using structured testing quarterly lowered A1C by 0.3%, which is better than some meds.
Meanwhile, in a separate section on improving care and promoting health, the ADA gives a nod to telemedicine (including web portals and text messaging) as a “growing field that may increase access to care for patients with diabetes,” especially “rural populations or those with limited physical access to health care.”
For the first time, the American College of Cardiology (ACC) is on board with the ADA, endorsing the new Standards; while the ADA in turn endorsed the ACC’s atherosclerotic cardiovascular disease risk calculator, called ASCVD Risk Estimator Plus. If you’re not familiar with ASCVD, it’s coronary heart disease, cerebrovascular disease, and peripheral arterial disease, all lumped together. So basically, heart attacks, strokes, and all other bad heart ailments than can befall you. The ADA has been cheered by many heart docs for pulling no punches this year and clearly spelling out the dark facts in the Standards: “ASCVD… is the leading cause of morbidity and mortality for individuals with diabetes.”
Meet the Reaper. You can try it out yourself. The calculator that is, not death.
Enter some quick demographics (age, sex, and race all play parts in the risk) plus your blood pressure, cholesterol, smoking status, and a few details on your meds, and the calculator spits out your ten-year, and lifetime, risk of ASCVD. Then the fun begins. Click on the “determine therapy impact” button, and the calculator lets you click and unclick various therapy options to show to what percent various interventions reduce your risk.
It’s more entertaining than Pacman.
But the key message here is that even though heart stuff is the big killer, there’s much we can do to reduce our risk, and the Standards point out that “risk among U.S. adults with diabetes have improved significantly over the past decade.”
The ADA has also created a new cardiovascular education program in collaboration with the American Heart Association called Know Diabetes by Heat.
'Patient-Centered Care' for 2019... (Really?!)
This year, is “the focus and priority” of the Standards, according to an ADA press release. Really? Doesn’t that put the ADA about four years behind everybody else? Actually, this year’s Standards gives the exact same recommendation to adopt patient-centered care in diabetes treatment as it did in the 2018 Standards and the 2017 Standards before that.
What’s new this year is an expansion of supporting materials for diabetes-treating docs, including a number of new treatment algorithms to help docs to shift their mindsets and practice styles into a more patient-centered approach.
Also on the Menu
Drink more water, the Standards tell us, and fewer beverages with noncaloric sweeteners (i.e. diet soda). But when it comes to food, the ADA—no doubt still smarting from the legacy of the infamous “ADA diet”—emphasizes that there’s no one-size-fits-all eating pattern. Rather than giving docs a set of menus, the ADA advises packing patients off to a registered dietitian to “work collaboratively with the patient to create a personalized meal plan that considers the individual’s health status, skills, resources, food preferences.”
Although the Standards do give a thumbs up to the Mediterranean, DASH, and plant-based diets, as approaches that all “have shown positive results in research.” The ADA also says low-carb works for sugar control, but that studies show “challenges with long-term sustainability.”
In other good news, if you have both hypertension and diabetes, you no longer need to restrict your sodium intake beyond the level recommended for the general population of less than 2,300 mg per day (previously, it had been below 1,500 mg).
In the Medicine Cabinet
GLP1 is now first choice of injectables, before insulin, for T2s who aren’t reaching target goals on oral meds. And speaking of injections, a new section was added on proper injection technique to avoid lipodystrophy.
In other drug news, gabapentin (brand name Neurontin) is now on the neuropathic pain list due to “strong efficacy and the potential for cost savings.” And there Standards include a new table to help doctors assess risk of hypoglycemia.
- Keep your shoes on: the new Standards have shied away from foot inspections at every visit (except for those PWDs at high risk for ulceration); instead, and annual foot exam will do.
- Double checking: There’s a new recommendation to confirm a diabetes diagnosis with a second test from the same sample, for example doing both a fingerstick and an A1C from the same blood drop.
- Smoking included: Because smoking may increase the risk of type 2, a section on tobacco was added to the chapter on the prevention or delay of type 2 diabetes.
- No pills for expecting moms: Insulin is now on top of the list for pregnant women with sugar issues, as metformin and glyburide have both been shown to cross the placenta, while insulin appears not to.
- Empathy talk: Yet again, the Standards take a stab at getting doctors to successfully talk to patients. This time, “new text was added to guide health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style.” Among other items in this section, docs are told that “person with diabetes” is preferred over “diabetic.” And to be nonjudgmental, use language free from stigma, and to impart hope.
- Moving targets: Rather than set specific blood pressure targets, the new Standards recommend an individualized approach, based on cardiovascular risk.
- Nix the e-cigs: Based on new evidence, a recommendation was added discouraging e-cigarette use in youth.
- T2 kids: Speaking of youth, the section on type 2 in kiddos has been “significantly” expanded.
- Easing up on geriatrics: And lastly, for elders, "de-intensification" and "simplification" are now the watch words, complete with a complex flow chart on how to simplify the treatment process.
A Living Document
As in recent years, the online version of the Standards is a “living” document, and will be updated throughout the year as new changes “merit immediate incorporation.”
The world changes quickly.
Speaking of the world, the Standards also address the issues of the financial costs of diabetes, to both individuals and to society, by linking the Standards to the ADA’s much-touted Insulin Access and Affordability Working Group findings from June of last year, which reported that between 2002 and 2013, the cost of insulin nearly tripled. The reason for skyrocketing costs? The Group said the reasons were “not entirely clear.” Nice way of avoiding the term greed, don’t you think?
But in fairness, the Group did an excellent detailed analysis of the complexity of the insulin supply chain. Their final recommendations are largely wishful thinking. Still, at least the ADA’s clout lends legitimacy to discussions of the problems and raises awareness of the issue higher among doctors and perhaps in political circles too.
And adding advocacy to Standards only makes the effort stronger, so this is a change to appreciate.